revised 1.27.21
CONTRA COSTA COUNTY COMMUNITY HOMELESS COURT
Send this completed form with a letter of support to homelesscourt@cchealth.org or fax to 925-608-6741
If other transmittal arrangements need to be made, please contact the Homeless Court Coordinator @ (925) 608-6700
AUTHORIZATION TO SHARE PROTECTED PERSONAL INFORMATION
I give authorization for my basic and personal information (including, but not limited to, name, gender, birth date, ethnicity, marital status, household configuration, military
status, primary language spoken, and non-confidential services requested and received) to be shared with the organizations with which the Contra Costa Public Health
Homeless Program operates and authorized staff of partner agencies in order to assist me in gaining access to services that I may need including housing, employment,
financial assistance, vocational services, counseling and medical/mental health treatment.
I understand that authorizing my information to be entered into the HMIS is voluntary. I understand that I have the right to receive a copy of my HMIS information upon
written request. I understand that I may cancel this authorization at any time by written request to the County Homeless Program at 2400 Bisso Lane D2, Concord, CA 94520,
but that the cancellation will not be retroactive. I understand that this release is valid for three years from the date of my signature below.
Print Name of Participant Signature of Participant Date
APPLICANT INFORMATION:
First Name: MI: Last Name: Phone Date of Birth:
California Driver License No.: SS No.:
Is client currently homeless : ☐ Yes ☐ No Was client homeless when ticket(s) received? : ☐ Yes ☐ No
Gender:
Male
Female
Transgender to
Transgender to
Other
Don’t know
Refused
Last Permanent Zip Code: (Last Permanent address where client resided for 90 days or more, not including time spent in transitional housing or institutions)
City Slept in Last Night:
☐ Alamo ☐ Canyon ☐ Diablo ☐ Lafayette ☐ Pinole ☐ San Ramon ☐ San Mateo County
☐ Antioch ☐ Clayton ☐ Discovery Bay ☐ Martinez ☐ Pittsburg ☐ Walnut Creek ☐ Santa Clara County
☐ Bay Point ☐ Clyde ☐ El Cerrito ☐ Moraga ☐ Pleasant Hill ☐ Alameda County ☐ Santa Cruz County
☐ Bethel Island ☐ Concord ☐ El Sobrante ☐ N. Richmond ☐ Port Costa ☐ Marin County ☐ Solano County
☐ Blackhawk ☐ Crockett ☐ Hercules ☐ Oakley ☐ Richmond ☐ Monterey County ☐ Sonoma County
☐ Brentwood ☐ Crockett ☐ Kensington ☐ Orinda ☐ Rodeo ☐ Napa County ☐ other CA County
☐ Byron ☐ Danville ☐ Knightsen ☐ Pacheco ☐ San Pablo ☐ SF County ☐ other U.S. City
Living Situation Last Night:
☐ Emergency shelter, including hotel or motel paid for with emergency shelter voucher ☐ Transitional housing for homeless persons (including homeless youth)
☐ Permanent housing for formerly homeless persons (such as SHP, S+C, or SRO Mod Rehab) ☐ Psychiatric hospital or other psychiatric facility
☐ Substance abuse treatment facility or detox center ☐ Hospital (non-psychiatric) ☐ Jail, prison, or juvenile detention facility
☐ Rental by client, no housing subsidy ☐ Rental by client, with VASH housing subsidy ☐ Rental by client, with other (non-VASH) housing subsidy
☐ Owned by client, no housing subsidy ☐ Owned by client, with housing subsidy ☐ Staying or living in a family member’s room, apartment or house
☐ Staying or living in a friend’s room, apartment or house ☐ Hotel or motel paid for without emergency shelter voucher ☐ Foster care home or foster care group home
☐ Place not meant for habitation ☐ Long-term care facility or nursing home ☐ Client doesn’t know
☐ Safe Haven ☐ Residential project or halfway house with no homeless criteria ☐Client refused to answer
Ethnicity:
☐ Hispanic/Latino ☐ Other (non-Hispanic/Latino) ☐ Don’t Know ☐ Refused
What BEST describes you? (check all that apply):
Latin heritage should mark American Indian if ancestry is from North, South or Central America. From Far East (including India) should mark Asian. From the Middle East should mark White.
☐ American Indian/Alaskan Native ☐ Asian ☐ Native Hawaiian/Pacific Islander ☐ White ☐ Black/African American ☐ Don’t Know ☐ Refused
Veteran: ☐ Yes ☐ No
Household Configuration: ☐ Single ☐ Couple without Children ☐ Female Single Parent ☐ Male Single Parent ☐ Two Parent Family ☐ Other ______
Disability Type: (Check all that apply. Indicate if it is expected to be of long duration, whether or not it’s documented & if client is currently receiving services for this condition.)
Long Term?(Y/N) Documented? Services (Y/N) Long Term (Y/N) Documented? Services (Y/N)
☐ Mental Illness _____ _____ _____ ☐ Physical Disability _____ _____ _____
☐ Alcohol Abuse _____ _____ _____ ☐ Developmental Disability _____ _____ _____
☐ Drug Abuse _____ _____ _____ ☐ Chronic Health Condition _____ _____ _____
☐ HIV/AIDS & related diseases _____ _____ _____ ☐ Other: _______________________ _____ _____ _____
Currently on probation (Y/N): _____Probation end date (mm/dd/yy): Currently on parole (Y/N): _____Parole end date (mm/dd/yy): _____/_____/_____
Were you released from state prison or sentenced to jail and/or mandatory supervision under California Assembly Bill (AB) 109? (Y/N): __
RECOMMENDING CASEWORKER INFORMATION:
Caseworker Name: Organization:
Address:
Phone (required): Email (required):
(Confirmation receipt of referral and assigned court date will be sent to this email address)
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signature
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