DVBEDS New Customer Registration and Intake Form

  • DVBeds Registration

    Please complete the following registration to join DVBeds. Once your information is received, a DVBeds team member will reach out to begin the onboarding process.
  • Are you an Organization or an Individual Operator*
  • Does your organization work to place survivors of domestic violence, intimate partner violence, or sexual assault into emergency housing?*
  • Are services offered for free*
  • Do you have a dedicated department, programming, or staff that specifically serve survivors of domestic violence, intimate partner violence, and/or sexual assault?*
  • Is your organization's PRIMARY focus batterer intervention (BIPP), intervention for people who cause harm, or anger management?*

  • Based on your inputs above, your organization does not meet the qualification requirements for participation in the DVBeds program. If you have any questions, please reach out to us: Contact Us

  • Format: (000) 000-0000.

  • Facility/Agency Administrator Information

    Internal Information for Shelter/Facility Management (Internal to DVBeds)
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Shelter/Facility Capabilities and Service Offerings

    Please check all of the services that are offered by your shelter (NOTE: These criteria will be used in system searches on the DVBEDS application when others are seeking specific shelter and service offerings along with bed space and availability)

  • General Services

  • Please check the box next to all of the services that are offered by your facility.

  • Shelter Gender and Youth Services

  • Please check the box next to all of the services that are offered by your facility.

  • Special Populations Served

  • Are your services restricted to only the special populations listed above?

  • Shelter/Facility Bed Capacity and Availability

  • Does your facility provide shelter beds in more than one location?
  • Do Singles share rooms?
  • Do Families share rooms?
  • Do you utilize Hotels for Overflow?

  • Service Restrictions or Limitations

    This section is where a shelter/facility can list any restrictions on services provided based on where the person needing shelter resides or other demographic or gender factors. This information will help better define system searches for bed lookups and appropriate facility recommendations for placement.
  • Does your Shelter accept DV Survivors that may have pets or service animals?
  • Does your facility provide shelter for MEN?
  • In order to receive shelter at your facility do the Men need to be accompanied by a child? Please check the one that applies to your shelters policy for Men.

  • Country, State, or County Limitations:

    This section helps us identify any specific Country, State or County service limitations that my apply to the services offered by your facility. Some facilities have no restrictions and others have policies that we want to make sure we capture.
  • Does your facility only provide services to individuals seeking shelter that reside in or come from a specific Country, State, or County?

  • Countries

  • Is your facility able to accept individuals from all countries? If YES, Please proceed to the next question.

  • States

  • Is your facility able to accept individuals from all States? If YES, Please proceed to the next question.

  • Counties

    Please type in the field below if your Shelter only receives individuals from certain Counties and please list the specific Counties that you serve.
  • Should be Empty: