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OUSING FOR
HEALTH OC

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सम्पर्क गर्नुहोस्
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Our Impact

Jamboree Housing

HELP STARTS HERE

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

Alternate Phone (Famliy Member/Friend)

Their Name

Referring Organization (if applicable)

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

Yes

Not Sure

Mailing Address

Physical Address

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

Pets:

Yes

Type of Pet

Number of Pets

Service Animals

Yes (Certified)

Not Sure

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

Yes

If Yes, Who With:

Spots Frequented

Health Conditions/Concerns:

CIN #

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

Not sure

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