House of Rebirth Resource Intake Form 🏳️⚧️
Connect with support and resources tailored to your needs.
Contact and Safety Preferences
Legal name if different
Chosen / preferred name
*
Pronouns
Please Select
She/her
He/him
They/them
Self-describe
Date of birth
*
-
Month
-
Day
Year
Date
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
City and state
*
ZIP code
Best way to contact
*
Please Select
Phone
Text
Email
Other
Safe to leave a voicemail?
*
Yes
No
Safe to send text messages?
*
Yes
No
Emergency and Urgent Need Screening
Emergency Acknowledgement
Are you currently in immediate danger?
*
Yes
No
Do you need emergency shelter today?
*
Yes
No
Do you need food today?
*
Yes
No
Are you experiencing a medical emergency?
*
Yes
No
Do you have an urgent legal need?
*
Yes
No
Do you need crisis support right now?
*
Yes
No
Service Needs and Routing
Service needs checklist
*
Housing support
Emergency shelter referral
Rental or utility assistance referral
Food assistance
Clothing or hygiene items
Transportation support
Employment or job readiness
ID or document support
Name and gender marker change support
Healthcare navigation
HIV/STI testing referral
Mental health support
Substance use support
Domestic violence or safety planning
Reentry or incarceration support
Family or parent resources
Youth resources
Elder resources
Insurance or benefits navigation
Case management or resource navigation
Community support groups / Chat n Chew
Event or program registration
Advocacy support
Other
If other, please describe
Top 3 needs
*
Urgency level
*
Low
Moderate
High
Immediate
Have you already contacted any agencies about these needs?
*
Yes
No
Not sure
Barriers you are facing
Current housing situation
*
Please Select
Stable housing
Temporary housing
Shelter
Unsheltered
Staying with friends or family
Hotel or motel
At risk of losing housing
Other
Household size
*
Income / employment status
Please Select
Employed full-time
Employed part-time
Unemployed and seeking work
Unemployed and not seeking work
Self-employed
Student
Retired
Unable to work
Other
Insurance status
Please Select
Private insurance
Medicaid
Medicare
Uninsured
Other
Transportation access
Please Select
Own vehicle
Public transit
Rides from others
Limited access
No reliable transportation
Other
Preferred appointment or follow-up times
Consent, Confidentiality, and Signature
Permission to share information with partner organizations for referrals
*
Yes
No
Consent to be contacted by House of Rebirth
*
Yes
No
I acknowledge that I have read and understand the confidentiality statement
*
I acknowledge and agree
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: