Coordinated Entry Form

Coordinated Entry

Please fill out the form below to determine eligibility. If you are in a home seeking RENTAL ASSISTANCE, please call 211 for assistance.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.(Do NOT include a 1 at the beginning.)
Email
example@example.com
Head of Household's Age*
Preferred Method of Contact*

Phone CallText
If you have a phone, what type of phone plan do you currently have?*

Unlimited Minutes and TextLimited Minutes and TextWi-Fi Only
Are you currently in fear of your safety due to domestic violence?*

YesNo
Is it safe to leave a message?

YesNo
Did you sleep in Pierce County, WA last night?*
Where did you sleep last night?*
How was the Hotel/Motel paid for?
Were you in the facility for 90 days or more?
Before entering the facility where did you sleep?
Please verify that you are human*
Should be Empty: