OUSING FOR
HEALTH

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

First Name

Name of person completing (if not client)

Last Name

Referring organization (if applicable)

Personal phone

Ok to call?

Yes

No

Email

Date of birth

City

County

Are you enrolled in Medi-Cal?

Yes

No

What health plan do you have?

Kaiser

CalOptima

Other

How many people are in your immediate family?

How many minors?

If other, list health plan here:

Are you currently: *

Homeless

At risk of homelessness

Looking to help someone else

Please share any additional information that will help us get you the support you need (do you need housing assistance, medical assistance, or both?)

Release of Information: I hereby authorize Housing for Health to use my 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