Referral sheet new
Exit Survey
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The CoC's Coordinated Entry System in conjunction with QuestionPro are HIPAA Compliant.
Do you agree to have your info collected thru question pro?
No (Please Exit Survey)
Yes
Are you in a safe place?
Yes
No
Are you currently living or trying to leave an intimate partner relationship that makes you feel threatened or fearful?
Yes
No
Do you give us permission to share your information with the agencies you are referred to?
Yes
No
Where is the last place you lived?
What is today's Date
Are there children in your household?
Yes
No
The household includes:
Adults
Children
Contact Information of the Client
First
Last Name
Phone
Email Address
Who is making the referral?
-- Select --
Alliance
Care Center
City of Fayetteville
Connections of Cumberland County
Cumberland County
Cumberland HealthNet
Easter Seals
Endeavors
Family Promise
Homeless Officer
Hope 4 NC
Hope Center
Life Matters Too Care Center
Operation In As Much
Other
Salvation Army
Veteran Crisis Line
Veteran Services of the Carolina's
ABCCM
Manna Dream Center
Are you a Civilian or a Veteran?
Civilian
Veteran
Where did you sleep last night?
Outside
Car
Friends/family
Shelter
Home
Hotel
Hospital/institution
Please tell us how we can help?
Done
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