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.)Format: (000) 000-0000.
Email
example@example.com
Head of Household's Age*
Phone CallText
Unlimited Minutes and TextLimited Minutes and TextWi-Fi Only
YesNo
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?
Assigned Staff
Contact Status
Screening Result
Source
Notes
Please verify that you are human*
Should be Empty: