DVBeds New Shelter/Facility Registration
New Facility or Agency Initial Intake Form PLEASE COMPLETE THE FOLLOWING REGISTRATION PAGES TO JOIN THE DVBEDS SYSTEM. ONCE YOUR SUBMISSION AND SHELTER OR AGENCY INFORMATION HAS BEEN RECEIVED, A DVBEDS TEAM MEMBER WILL REACH OUT TO YOU DIRECTLY TO START THE ONBOARDING PROCESS.
Facility/Agency Full Name
*
Please enter the full name for your Facility or Agency Requesting DVBEDS system access.
Brief Description of the Services offered by your Shelter/Facility/Agency
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Complete Address (Note: This information will not be shared publicly but is required for system registration only - For system geolocation only a general zip code will be used)
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Shelter/Facility Hotline Main Number (Public Facing)
*
Please enter a valid phone number.
Website
Facility/Agency Administrator Information
Internal Information for Shelter/Facility Management (Internal to DVBeds)
Administrator/Director Full Name
*
First Name
Last Name
Administrator/Director Title
*
Administrator/Director Email Address
*
example@example.com
Administrator/Director Direct Line
*
Please enter a valid phone number.
Administrator/Director Mobile Number
Please enter a valid phone number.
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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.
Emergency Financial Assistance
Food Assistance
Household Basic Needs
Health Services
Transitional Housing
Transportation Assistance
Domestic Violence Prevention Counseling
Case Management for Domestic Violence Survivors
Childcare Help for Domestic Violence Survivors
Domestic Violence Child Counseling
Emergency Shelter Transportation
Domestic Violence Support Group
ADA Accessible
Shelter Gender and Youth Services
Please check the box next to all of the services that are offered by your facility.
Shelter Serves Adolescent boys
Shelter serves youth males
Nonresidential Services available for Men
Shelter Serves Men
Sexual Assault Services
Domestic Violence Shelter
Nonresidential Domestic Violence Services
Nonresidential Domestic Violence Services for Youth
Domestic Violence Youth Shelter
LGB Youth Services
Parenting Education/ Support for Pregnant or Parenting Youth
Services for Parents of Youth Survivors
Special Populations Served
Please list any specialized populations you serve. Please list each separated by a comma. For Example (Ethnicity, Age, Religion, Etc.)
Are your services restricted to only the special populations listed above?
Yes
No
Description of any services you provide to the above population that you would like noted in the system.
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Shelter/Facility Bed Capacity and Availability
Does your facility provide shelter beds in more than one location?
Yes - Multiple Locations
No - Single Location Only
Total number of SINGLE BEDS available at your Shelter.
Do Singles share rooms?
Yes
No
Total number of FAMILY BEDS available at your Shelter.
Do Families share rooms?
Yes
No
Do you utilize Hotels for Overflow?
Yes
No
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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?
Yes
No
Does your facility provide shelter for MEN?
Yes
No
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.
Men can receive shelter without a child/children.
Men can receive shelter only with a child/children.
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?
Yes - We have some restrictions.
No - We have no restrictions.
Countries
Is your facility able to accept individuals from all countries? If YES, Please proceed to the next question.
Yes - We accept individuals from All Countries
No - We have some Country restrictions
Please select all countries that you are able to receive individuals seeking shelter.
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
States
Is your facility able to accept individuals from all States? If YES, Please proceed to the next question.
Yes - We can accept individuals from All States.
No - We have certain restrictions on individuals from certain States.
Please select all States that you are able to receive individuals seeking shelter.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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.
List all Counties that you serve and separate each with a comma.
Example: Marion County, Columbia County' etc...
Please use the space below to indicate any other service related restrictions or limitations that need to be noted about your shelter.
Date
Please verify that you are human
*
Submit
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