TSA OUTREACH FORM (Cascade Division)

HUD PDX Outreach Intake Form
Wednesday, December 4, 2024
Today's Date:
12/04/2024
Client Date-of-Birth
12/25/1900
Client Name:
Phillip Emery
Nearest Address to Location:
123 N Pole Rd
North Pole, AK, 66666
Relationship to Head of Household:
Self
INCLUSIVE IDENTITY INFORMATION:
Is client a veteran?
No
Identified Gender:
Woman (girl if child)
Race and Ethnicity:
Client does not know
VULNERABILITY INFORMATION:
Is the client actively fleeing domestic violence
No
Does client have a disabling condition?
No
Prior living situation:
Rental by client with subsidy
Length of stay in previous place:
1 week or more, but less than 1 month
Approximate date of homelessness:
07-04-1492
Not counting last night, number of times that client has been on the streets, in emergency shelter or safe harbor in the past three years:
1 time
Total number of months client has been homeless on the street, in emergency shelter or safe harbor in the last three years:
1-12 months
Specific number of months client has been homeless on the street, in emergency shelter or safe harbor in the last three years:
1 month
LANGUAGE ASSISTANCE INFORMATION:
Primary Language:
Albanian
Language Assistance Needed:
Yes
OUTREACH WORKER INFORMATION:
Outreach Worker Name:
Phillip Emery
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