HMIS Services Request Form
You may submit additional services to this list under the "other" section under each service category. *Please note that services set up turnaround is within 7 business days of form submission*
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Your Agency
*
Program Name (as it appears in HMIS if already set up)
*
Do you want us to mimic the exact same services that you have in another one of your programs? If so, you do not need to fill out the rest of this form.
*
Yes
No
What is the HMIS Program Name whose services should be mimicked?
CASE MANAGEMENT
Advocacy
Assessments
Benefits Assistance
Case Management
Check-Out
Check-In
Contact
Enrollment
Information and Referral
Other Case Management Services (Optional)
CHILD CARE ASSISTANCE
Child Care Assistance
Day Care
Other Child Care Assistance Services (Optional)
CREDIT REPAIR
Budgeting Class
Credit Repair
Other Credit Repair Services (Optional)
EDUCATION ASSISTANCE
College Prep
Education Assistance
GED
Other Education Assistance Services (Optional)
EMPLOYMENT ASSISTANCE
Career Goals
Employment General Services
Job Search
Referrals
Resume' Assistance
Other Employment Assistance Services (Optional)
FINANCIAL ASSISTANCE
Financial Assistance
Limited Financial Assistance
Other Financial Assistance
Other Financial Assistance Services (Optional)
FOOD ASSISTANCE
Food Assistance
Food Bank
Food Baskets
Other Food Assistance Services (Optional)
HC (HEALTH CARE)
Dental Serivces
HC Assistance
HC Referrals
Hospitalization
Medical Services
Medication
Other HC
Other HC Services (Optional)
HOUSING
Bed Night (for Night-by-Night shelters only)
Other Housing Assistance Services (Optional)
HOUSING SEARCH AND PLACEMENT
Housing Applications
Housing Assistance
Housing Inspection
Housing Lease-up
Housing Placement
Housing Recertification
Housing Search
Housing Support
Other Housing S & P Services (Optional)
LEGAL SERVICES
Advocacy
Legal Service Referrals
Legal Services
Other Legal Services (Optional)
LIFE SKILLS
Groups
Laundry Services
Life Skills
Personal Enrichment
Other Life Skills Services (Optional)
MH (MENTAL HEALTH)
Groups
MH Referrals
MH Services
MH Treatment
Other MH services (Optional)
MOTEL AND HOTEL VOUCHERS
Motel and Hotel Vouchers
Other Motel/Hotel Voucher Services (Optional)
MOVING COST ASSISTANCE
Moving Cost Assistance
Other Moving Cost Assistance Services (Optional)
OTHER
Material Goods
Other
Other Outreach
Other Services (Optional)
For services that do not fit in any other category
RENTAL ASSISTANCE
Rental Assistance
Other Rental Assistance Services (Optional)
SECURITY DEPOSIT ASSISTANCE
Security Deposit Assistance
Other Security Deposit Assistance Services (Optional)
SMT (SUBSTANCE MISUSE TREATMENT)
Detox
Groups
SMT Services
SMT
Other SMT Services (Optional)
TRANSPORTATION ASSISTANCE
Bus Pass
Bus Tokens
Bus Tickets
Transportation Assistance
Other Transportation Assistance Services (Optional)
UTILITY DEPOSIT
Utility Deposit
Other Utility Deposit Services (Optional)
UTILITY PAYMENT
Utility Payment
Other Utility Payment Services (Optional)
Submit
Should be Empty: