Coordinated Entry
Housing Eligibility Screening
For Residents of
Grays Harbor and Pacific County

Todays Date *

mm/dd/yyyy

County of Residence *

Do you have an FCS Provider

Yes

No

Unsure

Were you referred by another person or agency? *

Person

Agency

No

First Name, MI *

Last Name *

Date of Birth *

mm/dd/yyyy

Phone Number *

Email

Current living Situation *

Length of Time in Current Living Situation *

Services Being Requested

Questions/Comments

Heading

*

Send me a copy of my responses

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Coordinated EntryHousing Eligibility ScreeningFor Residents of ﻿Grays Harbor and Pacific County