• BHRC Outreach Form

    Revised 7/15/2026
  • BHRC Outreach Staff, April 2025

  • Complete this form after engaging with a peer or a community member offsite, away from the BHRC. Responses will be used to track service interest and service referrals in a 4-block radius from the BHRC.

  • Your Supervisor*
  • Please mark all staff members involved*
  • Type of Encounter:*
  • Today's Date*
     - -

  • BHRC 4-block radius
    SW Yamhill to NW Everett and 13th Ave to 4th Ave
    Additional focus on Central Library, 11th & Jefferson

  • Image field 62
  • Where was the encounter?*
  • Was this a Dispatch call?*
  • Queuing Time*
  • How long was the encounter?*
  • Did you successfully have a conversation with the individual(s)?*
  • Did you leave them with any of the following? Leave blank for none
  • What service(s) was the individual(s) interested in or in need of? Leave blank for none

  • Important Definitions

     

    INFORM - Give the individual information about a service.
    Example: Gave the individual information about Hooper Detox.

    REFER - Complete needed steps so the individual can access a service. Get the individual a "placement" in a service. 
    Example: Completed needed paperwork to get an individual a bed at Hooper Detox.

    CONNECT - A step beyond refer. Peer staff can verify that the individual utilized the referral.
    Example: Drove the individual to their placement at Hooper Detox.

  • Was the individual already connected to services?*
  • DEPRECATED// Did you INFORM the person(s) about services available at the BHRC?*
  • Did you REFER the individual to a service?*
  • Did you also CONNECT the individual to said service(s)?*
  • Why was the individual not REFERRED/CONNECTED?*
  • DEPRECATED// Did you CONNECT the person(s) to the BHRC?*
  • DEPRECATED// What did you observe the person(s) doing prior to interacting with them? (mark all that apply).
  • DEPRECATED// Did you INTRODUCE yourself as a representative of the BHRC?*
  • DEPRECATD// Did you direct them/provide entry into the BHRC or ticket for a queue?
  • DEPRECATED// Did you ask that they move to a new location?

  •      HMIS Referral Jotform

  • If you gave out a CityTeam voucher, don't forget to fill out a:

        CityTeam Voucher Jotform

  • If you gave out a bus ticket, don't forget to fill out a:

        Bus Pass Jotform

  • Is there a follow-up plan?*
  • What is the follow-up plan?*
  • Should be Empty: