Home More Network: New Client Form
CLIENT INFO
Full Legal Name
*
First Name
Last Name
Middle Name (Optional)
Other Preferred Names/Nick Names/Aliases
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Do you have a phone?
*
Please Select
Yes
No
Is texting you okay?
*
Please Select
Yes
No
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HOUSEHOLD INFO
Name(s), Date(s) of Birth and Relation to you (head of household) for people that live with you currently. If you live alone, write N/A
First and Last Name
Date of Birth MM-DD-YYYY
Relation
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2
3
4
5
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7
8
How many and what types of animals live with you?
0
1
2
3
4+
Dog(s)
Cat(s)
Other
Where are you currently sleeping?
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Shelter
Vehicle (personal vehicle, car, truck, etc.)
RV or Trailer
Tent
Outside
Other
If "Shelter" or "Other", please explain in more detail where and what the circumstances are/how long you are able to stay...
Are you staying at an encampment in Deschutes County?
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China Hat
Horse Butte
Juniper Ridge
Camping in town in Bend City limits
Camping at a campground
Encampment in Redmond
Encampment in La Pine
None of the above
Mailing Address (If None, Write "N/A")
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you need a mailing address?
*
Please Select
Yes
No
Are you or your spouse a veteran?
*
Please Select
Yes
No
Are you or your spouse currently pregnant?
*
Please Select
Yes
No
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HELP NEEDED
What are you needing help with? (Multiple okay)
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Basic needs: food, water, propane, supplies
Help to get an ID
Help to get a driver's license
Help to get a birth certificate
Help applying for SNAP, OHP, TANF
Help connecting to a primary care medical doctor
Help connecting to a licensed mental health therapist or counselor
Help to flee current domestic violence or sex trafficking
Support for families with children
Help through a CPS case to get custody of children
Support for aging and/or disabilities
Help to apply for SSI/SSDI
Help to pay off debts to improve credit score
Help to connect with substance use detox treatment centers/support
Cultural specific support
Legal aid or help to expunge your record
Financial assistance: paying a bill (not related to vehicles)
Help to purchase a vehicle
Vehicle specific needs: fuel, car insurance, DMV fees, vehicle repairs
Shelter information
Referral for a motel type of shelter
Referral for housing programs
Safe Parking
Help applying to village(s)
Housing navigation
Case management
Personal Development: Working toward personal goals with mentors
Other
If "Other" needs, please specify...
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IDENTIFYING BARRIERS
Do you experience any chronic medical conditions or disabilites that limit your ability to work or secure housing? This answer can be YES or NO. If you would like to share, this is to help us understand anything you may experience that could be a barrier to housing or employment.
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If a shelter or housing program requires a criminal background check, would anything show up (YES or NO) and how long ago did it happen? If you want to share details, you can. It is not required to go more in depth here. We can explore this more later depending on the programs or resources you may be interested in.
*
How do you cope with being unhoused? Do you have any vices, substances, habits or mental processes that you depend or rely on? *This question does not have any bearing on our ability to offer help or services to you. Honesty here helps us to understand your struggles so we can offer the best support possible depending on your needs and interests in resources.
*
Do you currently have any form of income? If yes, please explain the source(s) of income, amount and if it is monthly, weekly or biweekly. We ask this because some housing resources want to know if clients fit within certain program guidelines.
*
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IDENTIFYING GOALS
Prior to becoming unhoused: Who were you? What were your hopes, dreams and goals? In what ways has being unhoused changed you if any?
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A bit about your current circumstances... Are you working toward anything currently that you consider a goal for yourself for 2025? If yes, can you please explain what the next few steps toward that goal would be in case we might be able to help directly or point you toward additional resources?
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Close your eyes. Take a deep breath. Imagine you are no longer in survival mode. You are free to be and do as you please. What would you like your next chapter to look like? What goals do you want to work toward? What is your favorite version of yourself like if all of your goals and dreams work out well?
*
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CASE MANAGER(S) AND REFERRALS
How did you hear about us?
*
Please Select
NONPROFIT SERVICE PROVIDER
FRIEND
CHURCH
NEWSPAPER
INTERNET
MAGAZINE
OTHER
Please Specify
*
Are you currently working with other nonprofits, case managers or advocates?
*
Please Select
Yes
No
If yes, who are you working with?
Full Name
Organization
Contact Number
1
2
OUTREACH: If you are not already connected with services from the following organizations... Please select any local non-profit outreach service providers you would like HMN's team to connect you with as a referral to begin services:
CAMP - Companion Animal Medical Project
COVO - Central Oregon Veterans Outreach
DCBH - Deschutes County Behavioral Health
MOSAIC - Mosaic Medical
REACH - Reach Out Central Oregon
SVDP - St. Vincent de Paul
SHARE - Shepherd's House Ministries SHARE Van
SHELTER / HOUSING PROGRAM TYPE REQUIREMENTS:
High Barrier:
UA drug testing
Criminal background check (Usually checking for sex offenses and person-on-person violence charges)
Low-Barrier:
No drug testing
No criminal background checks
If working with HMN toward shelter and housing referrals, what types of prgrams are you most interested in...
Please Select
High-Barrier
Low-Barrier
Both High and Low-Barrier programs
Have you contacted Homeless Leadership's Coalition's (HLC's) Coordinated Entry System (CES) Hotline?
*
Please Select
Yes
No
Unsure
Have you completed a H.E.A.T. Vulnerability Assessment in the last 6 months?
*
Please Select
Yes
No
Unsure
SHELTER / HOUSING REFERRALS: If you are not already connected with services from the following organizations... Please select any local non-profit shelter or housing service providers you would like HMN's team to connect you with as a referral to begin services:
Bethlehem Inn: Communal living shelter program in Bend and Redmond
BIRCH by Bethlehem Inn: Motel-type shelter program in Redmond
Central Oregon Villages: Multiple Programs in Bend
Cleveland Commons Apartments: Permanent Supportive Housing (PSH) based on medical needs (Central Oregon FUSE and Shepherd's House Ministries) in Bend
Franklin Shelter: Motel-type Shelter in Bend (REACH and SHM)
Long-Term Rental Assistance (LTRA): NeighborImpact
Mosaic: Medical related housing
Oasis Village: Tiny home village in Redmond
Old Mill Apartments: Motel-type apartments to help to re-establish rental history in Bend
Safe Parking in Bend: (REACH, COV, Mountain View Community Development)
Safe Parking in Redmond: (Mountain View Community Development)
St. Vincent de Paul (SVDP): Village or Duplexes in Bend
Stepping Stones: Motel-type Shelter in Bend (NeighborImpact)
Shepherd's House Ministries (SHM): Multiple Programs
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EMERGENCY CONTACTS AND RELEASE OF INFORMATION
Emergency Contact (If you become unreachable or in case of emergency):
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Full Name
Address
Contact Number
1
2
RELEASE OF INFORMATION: Do you give us permission to contact your case managers at other organizations, your emergency contact if necessary and other churches or organizations to source resources for you on your behalf?
*
Please Select
Yes
No
Further Discussion Needed
HMIS: We honor your privacy. Home More Network has an obligation under funding guidelines to keep track of our services in HMIS. This is also needed for anyone seeking referrals for longer term shleter, village or rental assistance programs in Central Oregon. Do you agree to be added to HMIS (Homeless Management Information System)?
*
Please Select
YES, ADD ME TO HMIS DATABASE
NO, I REFUSE TO BE ADDED TO HMIS DATABASE
From HUD's website: https://www.hudexchange.info/programs/hmis/ HMIS is a local information technology system used to collect client-level data and data on the provision of housing and services to individuals and families at risk of and experiencing homelessness. Each CoC is responsible for selecting an HMIS software solution that complies with HUD's data collection, management, and reporting standards.
Typing your name here indicates that the above information is true to the best of your knowledge and that you are requesting registration to become a client with Home More Network. This application to register as a client does not guarantee services, however, if we are not able to help meet your needs, we will offer suggestions of resources that may be able to better serve you.
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Last Name
Date
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