Intake Form

Instructions for Completing Referral Form

Use the following three steps for connecting an unsheltered person with Coordinated Entry:

1. Ask the client what their living situation is.

Unsheltered means sleeping in places not meant for human habitation, which include: streets, parks, alleys, parking ramps, parts of the highway system, transportation depots and other parts of transportation systems (e.g. subway tunnels, railroad cars), all-night commercial establishments (e.g. movie theaters, laundromats, restaurants), abandoned buildings, building roofs or stairwells, chicken coops and other farm outbuildings, caves, campgrounds, vehicles, and other similar places.

2. Please complete both pages with the client’s contact information.

If the client is sleeping unsheltered, please complete the contact information as completely as possible with the client.

3. Fax form to 828.388.7980.

Our Blue Ridge Health Street Outreach Team will follow up with the client