Housing placement referral form (for MCCAC and partner use only)

First name of client*

Last name of client*

Client phone number (write N/A if not applicable)*

Client shelter situation*

Shelter

Hotel voucher

Not sheltered but getting street outreach services

Client's current county of residence*

Wasco

Sherman

Hood River

Other

Date of referral*

Name of shelter or outreach staff making referral*

Does client have plan for finding housing?*

Yes

No

What is the plan for finding housing?*

Does client have plan for paying ongoing expenses?*

Yes

No

What is the plan for paying for ongoing expenses?*

Identification/ paperwork needs*

Needs assistance obtaining social security card

Needs assistance obtaining birth certificate

Needs assistance obtaining state ID

Needs assistance obtaining driver's license

None of the above

Preference considerations*

4 or fewer barriers to housing on list above (1)

Lives or works in 1 of MCCAC's 3 counties (1)

Elderly-62 or older (2)

Disabled (2)

Family with children (3)

Fleeing domestic violence/sexual assault (3)

Medically fragile (3)

Plan/motivation for finding housing (3)

None of the above (0)

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