Pre-Screen Intake Form

Pre-Screen Intake Form

Welcome to our community’s Coordinated Entry. The information provided on this form will help us determine if you are eligible for Coordinated Entry. Upon receipt, you will be contacted regarding your eligibility. If you are eligible, an Intake appointment will be scheduled. If you are not, we will discuss the reasons for this determination and provide you with information on other resources that may be able to assist. If you have not received a response from us within 10 business days of submission, or if you need help completing this form, please contact us.
Please return via mail, email, or in person to the following:

HOPE for All Gulf Coast - 279 N. Washington Ave. Building B, Mobile, AL 36603 (251) 303-8058 coordinatedentry@hfal.org or outreach@hfal.org
Name

First NameLast Name
Veteran?

YesNo
Currently Fleeing Domestic Violence?

YesNo
Where are you currently located?

Mobile CountyBaldwin County
Please note:

HOPE for All Gulf Coast is only able to serve individuals and families experiencing homelessness in Mobile and Baldwin Counties.

If you are located outside of these areas, we encourage you to visit HUD's nationwide list located on www.hudexchange.info/ to find the appropriate service provider nearest you.
Gender
Last 4 Digits of SSN:
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Is there anyone else in your household? This may be an adult or child who is not currently living with you, but would live with you if you had housing.
Adult Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Relationship
Veteran

YesNo
Adult Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Relationship
Veteran

YesNo
Children (Only list children who are now, or would be if appropriate housing was obtained, in your legal custody.)

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Attending School

YesNo
Children (2)

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Attending School

YesNo
Children (3)

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Attending School

YesNo
Children (4)

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Attending School

YesNo
Is anyone listed above disabed?

YesNo
If yes, please provide the initials of the disabled individual(s) in your household.
Where did you, and the other members of your household, sleep last night? Please choose the appropriate location from below:
IF YOU ARE STAYING IN THE RESIDENCE OF ANOTHER PERSON OR IN A RESIDENCE YOU RENT/OWN have you been told by the person with whom you're staying, or received a court ordered eviction, indicating you must leave within the next two weeks?

YesNo
Today's Date

MonthDayYear
Date
For Staff Use Only
Date Received
Appointment Time
Staff Initial
Assigned Intake Specialist
Should be Empty:

Pre-Screen Intake Form

Please return via mail, email, or in person to the following:

For Staff Use Only