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OUSING FOR
HEALTH OC

Housing for Health Orange County

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Contact Us

We are ready to help you.

PARTNER WITH US

HELP STARTS HERE

Please complete the below form to the best of your ability.

First Name

Last Name

Preferred Nickname (if any)

Name of Person (if not client)

Middle Inital

Title

Referring Organization (if applicable)

Personal Phone

Ok to Call?

Yes

No

Alternate Phone (Famliy Member/Friend)

Their Name

Mailing Address

Physical Address

Family Members (that reside with client) and their phone numbers (if applicable)

Pets:

Yes

No

Type of Pet

Number of Pets

Date of Birth

Email

Service Animals

Yes (Certified)

No

Not Sure

Have you, or the client, currently, or have in the past, received housing services:

Yes

No

If Yes, Who With:

Spots Frequented

Health Conditions/Concerns:

Are you (or the client) enrolled in Medi-Cal:

Yes

No

Not Sure

Additional Notes:

How Did You Hear About HHOC

What Help Would You Like?

Housing Navigation Services

Housing Deposits

Housing Sustainability and Tenancy Services

Day Habilitation Services

Short Term Post Hospitalization

Enhanced Care Management

Release of Medical Information: I hereby authorize HHOC to use my medical information connected with these services, including but not limited to, insurance carriers, health networks, hospital workers, agencies and anyone assisting in obtaining coverage.

I consent

I do not consent

Thanks for submitting! You can expect a reply in 1-2 Business Days.

At-Risk and Homeless Service Providers

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Housing for Health OC

17701 Cowan

Suite 200

Irvine, CA 92614

info@housingforhealthoc.org

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© 2023 Housing for Health Orange County, Inc.

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