EBI HRC Self Referral Form

EBI Housing Resource Center Self Referral
Populations served:
- Adults with medical complexities who have greater service needs to address their healthcare
- Adults (55+) who may be eligible for prevention services
- Must be residing in Alameda County to be eligible for housing resource center services
Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you have a disability or chronic health condition? Examples include: difficulty walking for long distances due to shortness of breath or leg swelling; fatigue from treatments like chemotherapy or dialysis; weakness or paralysis from previous stroke, etc. *
If Yes, please explain
Are you residing in Alameda County?
Are you a Veteran?
Current Address or Location

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number where you can be reached
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Language
If other, what is your preferred language?
Your email address, if you have one
example@example.com
What type of services are you looking for?

Other
If other reason for services, please describe
Eviction status
Do you have documentation of shut off notice / past due rent or unpaid utility bills?
Are you willing to meet with an HRC team member to complete a comprehensive assessment in the HMIS system?
If there are any more details that can better help us understand your situation, please provide details below
Should be Empty:

EBI Housing Resource Center Self Referral