Bridges and Street Outreach Contact FormBridges and Street Outreach Contact Form Please fill out the form below and a housing or street outreach specialist will be in touch soon. To speak with a housing or outreach specialist, please call 402-437-8850. About Yourself:First Name *Middle Name *Last Name *Date of Birth *Gender *MaleFemaleTransgender identifies as MaleTransgender identifies as FemaleGender FluidOther...Sexual Orientation *HeterosexualLGBTQUnknownPrefer not to discloseOther...*CEDARS does not discriminate based on gender identity or sexual orientationLast Four Digits of Your Social Security Number *Where are you living right now? *Your Own House or ApartmentFriend's Home or ApartmentRelative's Home or Apartment ShelterHotelStreetCarCouch-SurfingOther...Address(Street, P.O. Box)City, State, ZipHow long have you been staying at this address?Phone Number *(including area code)Email Address *Tell us about your current living situation:Where are you currently staying? *(with family or friends, outside, in my car, motel/hotel)How many people live there? *Do you need to leave your current living arrangement within the next 14 days? *Are you currently trying to leave an unsafe situation or fleeing from domestic violence? *YesNoOther...Any additional information we should know?Have you experienced homelessness on the streets or in an Emergency Shelter in the past three years? *YesNoHow many times including today?Approximately how many months have you experienced homelessness on the streets or in an Emergency Shelter in the past three years? Why are you seeking assistance? *Have you ever been in any other Transitional Living Program? *YesNoWhen and where?Why did you leave that program?EducationName of the most recent school you attended and/or graduated from *Most recent year of enrollment/year you graduated *Problems you experienced in school/barriers to success *Family Information:Parent NameParent's Phone Number(including area code)Parent NameParent's Phone Number(including area code)Sibling(s) Names and AgesEmergency Contact Information:Emergency Contact #1 *(Name)Phone Number *Relationship *Emergency Contact #2 *(Name)Phone Number *Relationship *Your Health: In order for CEDARS to better understand what you have been through, please answer the following questions honestly: Are you pregnant or parenting?YesNoIf pregnant, how far along are you?If pregnant, are you getting prenatal care?YesNoWhere are you getting prenatal care?If parenting, please list child(ren)'s information:Child 1's NameChild 1's AgeChild 1's GenderFemaleMaleOther...Is the other parent involved?YesNoOther Parent's NamePlease list emergency contact names and phone numbers. If you have a child(ren), list the child/ren's other parent and/or a relative of the child/ren as an emergency contact.Child 2's NameChild 2's AgeChild 2's GenderFemaleMaleOther...Is the other parent involved?YesNoOther Parent's NamePlease list emergency contact names and phone numbers. If you have a child(ren), list the child/ren's other parent and/or a relative of the child/ren as an emergency contact.Child 3's NameChild 3's AgeChild 3's GenderFemaleMaleOther...Is the other parent involved?YesNoOther Parent's NamePlease list emergency contact names and phone numbers. If you have a child(ren), list the child/ren's other parent and/or a relative of the child/ren as an emergency contact.Child 4's Name Child 4's AgeChild 4's GenderFemaleMaleOther...Is the other parent involved?YesNoOther Parent's NamePlease list emergency contact names and phone numbers. If you have a child(ren), list the child/ren's other parent and/or a relative of the child/ren as an emergency contact.Any Health Concerns or Problems! *Legal:Are you currently on probation? *YesNoHow many months/years left?Probation OfficerProbation Officer's Phone NumberHave you ever been a ward of the state? *YesNoWhen?Case WorkerCase Worker's Phone NumberIndependent Living Skills: Are you currently employed? *YesNoPlace of employment: Number of hours worked per week: Do you currently receive assistance? *YesNoCheck all that apply:WICSNAPTitle XXHousingADCMedicaidSSIChild SupportOther…Transportation: Do you currently have a driver's license? *YesNoDo you have a car? *YesNoIf you have questions or need assistance, please call 402-437-8850.Submit
