Coordinated EntryHousing Eligibility ScreeningFor Residents of Grays Harbor and Pacific County

Coordinated Entry

Housing Eligibility Screening

For Residents of

Grays Harbor and Pacific County

Todays Date*

County of Residence*

Select

Do you have an FCS Provider

Yes

Unsure

Who is your FCS Provider

Comment:

Were you referred by another person or agency?*

Person

Agency

Who?

Which Agency?

Do you have a Care Coordinator/Case manager there?*

Select or enter value

Name of Care Coordinator or Case Worker

Care Coordinator or Case Worker phone number

First Name, MI*

Last Name*

Date of Birth*

Phone Number*

Current living Situation*

Select

Mortgage Assistance Information:

Contact our Aberdeen office and ask for the CCOD for more details or to apply for assistance.

101 E Market Street

Aberdeen, WA 98520

(360)533-5100

Unsheltered Homeless - Description*

Currently living outside or in a place that is not designed for, or ordinarily used as a regular sleeping accommodation for human beings, including a vehicle, park, abandoned building, or campground?

Sheltered Homeless - Description*

Residing in a temporary housing program including shelters, transitional or interim housing, and hotels and motels paid for by charitable organizations or government programs

Exiting a system of care or institution where they resided for 90 days or less AND who resided in an emergency shelter or place not meant for human habitation immediately before entering that system of care or institution

Residing in a trailer or recreational vehicle that is parked illegally or in a location that is not intended for long-term stays (i.e. parking lots)

Fleeing Domestic Violence - Desription*

Fleeing or attempting to flee domestic violence

Affected by dating violence, sexual assault, stalking, human trafficking, or other dangerous or life-threatening conditions against a household member, that has taken place within their residence or has made them afraid to return to their residence

At Risk of Homelessness - Description*

Renting a house or an apartment and have an eviction notice or a 14 day pay or vacate

Missed rent payment and currently owe all or part of a rent payment (current month or past months)

Living in the home of another because of economic hardship

Notified that their right to occupy their current housing or living situation will be terminated within 21 days after the date of application for assistance

Lives in a hotel/motel and the cost is not paid for by charitable organizations or by Federal, State, or local government programs for low-income individuals

Lives in an SRO or efficiency apartment unit in which there reside more than 2 persons or lives in a larger housing unit in which there reside more than one and a half persons per room

Is exiting a publicly funded institution or system of care

Length of Time in Current Living Situation*

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Services Being Requested

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Questions/Comments

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