• HMIS Referrals

    revised 7/27/2026

  • This is a Jotform for shelter and housing referrals provided by peer staff at the BHRC. Responses are confidential and protected by HIPAA.


    There are 13 questions. All questions are required.

  • Your Staff Supervisor*

  • Verbal Release of Information

    Read to the participant: “We are going to keep the information you give us in a system called ‘HMIS’. We use policies and different tools to protect that information. Collecting your info helps us organize our services and meet reporting requirements.

    In our community, many agencies help people who are experiencing homelessness or are unstably housed. Some of the information you give us will be visible to those agencies in HMIS. If you let us, we can share more details about you and the services you receive here with those agencies. Sharing your info can help agencies work together on future services you may qualify for.

    In rare cases, we may not need a release to share your information. For example, we may share your info to coordinate services with another agency. We would not share your info without a need. The privacy of your information is very important to us.

    Do you have questions about any of this?”


    “Do you agree to let us share your information in HMIS?”

  • Participant's Decision*
  • US Military Veteran?
  • Date of Birth
     - -
  • Relationship to Head of Household
  • Race and Ethnicity (Select all that apply)
  • Gender (Select all that apply)
  • Does the client have a disabling condition?
  • Prior living situation (Where did you stay last night?)
  • Length of Stay in Previous Place
  • Approximate date this episode of homelessness started
     - -
  • Regardless of where they stayed last night, number of times the client has been on the streets, in shelter, or safe haven in the past three years including today
  • Total number of months homeless on the street, in shelter or safe haven in the past three years
  • Project Start Date
     - -
  • Should be Empty: