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QUESTIONS

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

How Did You Hear About HHOC

First Name

Last Name

Middle Inital

Date of Birth

Preferred Nickname (if any)

Name of Person (if not client)

Personal Phone

Ok to Call?

Yes

No

Email

Alternate Phone (Famliy Member/Friend)

Their Name

Referring Organization (if applicable)

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

Yes

No

Not Sure

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

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:

CIN #

Additional Notes:

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

Your submission has been received. Please expect a response in 1-2 days.

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HEALTH OC

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At-Risk and Homeless Service Providers

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