Homeless Housing Shelter Referral & Community Resource Connections

COMMUNITY RESOURCE CONNECTIONS

Please allow 24-48 hours, Monday-Thursday, for a response. We are closed on the weekends. All submissions received on a weekend will be responded to on Monday mornings.
Date*

MonthDayYear
Date
Are you needing to flee from domestic violence?

If they answer "YES" give them the resources below as we are unable to provide resources for domestic violence situations at this time.

API-CHAYA (206) 325-0325

Snohomish County DV Services (425) 252-2873

(NO NEED TO FILL OUT THE FORM. END HERE)
Head of Household Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
If no email please put no@email.com
Current age?
Household Information
How many adults?*
How many children?*
Is anyone pregnant?

YESNO
Do you have pets?

YESNO
Have you contacted NorthSound 211 for Coordinated Entry Services? We will connect them with one when a housing team member calls them.*

YESNO
Are you currently employed or receiving cash benefits?*

YESNO
Does anyone in the home have a disability? If so, please describe medically documented disability.
Community Resource Connection
Are you in need of connecting to community resources?

Food BenefitsCash BenefitsHealth InsuranceFree/Low Income Cell Phone AssistanceFree/Low Income Internet ServiceUtility Assistance Referral
For students and their families of the Everett Public Schools there may be additional resources and/or referrals if you have a child actively attending in a Everett Public School. We do need to verify they are enrolled by asking for their name, school they attend, and student ID number.

(Proceed to next Question)
Do you have children that attend Everett Public Schools?
**If caller is not sure ask what school do they attend and check the list of Everett Public Schools below.
What school do they attend?
Child's Name

First NameLast Name
Student ID #
FYI ONLY

EVERETT PUBLIC SCHOOLS LIST

If their child(ren) does not attend any of the schools below put in notes which school they attend. Thank you.

ELEMENTARY SCHOOLS
- Cedar Wood
- Emerson
- Forest View
- Garfield
- Hawthrone
- Jackson
- Jefferson
- Lowell
- Madison
- Mill Creek
- Monroe
- Penny Creek
- Silver Firs
- Silver Lake
- Tambark Creek
- View Ridge
- Whittier
- Woodside
MIDDLE SCHOOL
- Eisenhower
- Evergreen
- Gateway
- Heatherwood
- North
HIGH SCHOOL
- Cascade
- Everett
- Henry M. Jackson
- Sequoia
Are you okay with us sharing your name, contact information, and current need with our community partners?

YESNO
RELEASE OF INFORMATION

We will need a release of information to share your information and need with our community partners. I will send you an email with a link to it. Our housing team will not be able to assist your until the release of information is submitted.

Send the caller an email with a link to our Release of Information. You can save the link below to your desktop pressing CONTROL key and clicking on the link at the same time. Then, select SAVE LINK AS or, you can copy and paste the link below to add to the email you send them.

LINK:

https://form.jotform.com/202044969831055
Is there any further information you would like us to know?
Place notes here
Should be Empty: