COVID-19 Outbreak Emergency Housing Grant - Client Referral / Registration

COVID-19 Outbreak Emergency Housing Grant - Client Referral / Registration
Date of Referral *

Month Day Year
Date
Referring Organization *
Person Referring *
Contact Phone *
Email Address *
example@example.com
Client's Last Name, First Name *
Client's Medical Current Provider. If none, type none. *
Street address if applicable If Homeless, indicate here. *
City
State
Zip code
Cell Phone
E-mail address
example@example.com
Does Client have Insurance *

Yes No
Insurance Carrier & Policy Information
Has Client been tested for COVID-19 *

Yes No
What were the results?
Who administered test?
Type of housing needed *
# of days housing is needed? *
Grant Purpose: Address COVID-19 outbreak related public health needs of people experiencing homelessness or otherwise in need of quarantine or isolation housing.
How does individual meet the following grant purpose? Please provide specific information regarding client and client's situation so that we can provide the most appropriate available housing as soon as possible. Thank you!
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