Homeless Providers Survey

Please Complete this Survey if Your Agency Provides Housing, Shelter, and/or Services to the Homeless.

If you prefer to complete a paper survey, please download the form here. Please note: this survey will be shared with the Lee County Continuum of Care Governing Board. Make sure that only ONE response is submitted per agency.

Section I: Agency Contact Information

Section II: Housing/Shelter Program or Agency Type. Click "Working Definitions" here for explanation of housing types

Emergency Shelter

Indicate the total number of each type of Emergency Shelter

Family Units
Target Population (See Target Populations here)

Family Beds
Target Population (See Target Populations here)

Individual Beds
Target Population (See Target Populations here)

Total Number of Beds (Cumulative Total)
Target Population (See Target Populations here)

Additional Comments

Transitional Housing

Indicate the total number of each type of Transitional Housing

Family Units
Target Population (See Target Populations here)

Family Beds
Target Population (See Target Populations here)

Individual Beds
Target Population (See Target Populations here)

Total Number of Beds (Cumulative Total)
Target Population (See Target Populations here)

Additional Comments

Permanent Supportive Housing

Indicate the total number of each type of Permanent Supportive Housing

Family Units
Target Population (See Target Populations here)

Family Beds
Target Population (See Target Populations here)

Individual Beds
Target Population (See Target Populations here)

Total Number of Beds (Cumulative Total)
Target Population (See Target Populations here)

Additional Comments

Rapid ReHousing/Rental Assistance

Indicate the total number of each type of Rapid ReHousing/Rental Assistance

Family Units
Target Population (See Target Populations here)

Family Beds
Target Population (See Target Populations here)

Individual Beds
Target Population (See Target Populations here)

Total Number of Beds (Cumulative Total)
Target Population (See Target Populations here)

Additional Comments

Other Permanent Housing

Indicate the total number of each type of Other Permanent Housing

Family Units
Target Population (See Target Populations here)

Family Beds
Target Population (See Target Populations here)

Individual Beds
Target Population (See Target Populations here)

Total Number of Beds (Cumulative Total)
Target Population (See Target Populations here)

Additional Comments

Medical Housing

Indicate the total number of each type of Medical Housing

Family Units
Target Population (See Target Populations here)

Family Beds
Target Population (See Target Populations here)

Individual Beds
Target Population (See Target Populations here)

Total Number of Beds (Cumulative Total)
Target Population (See Target Populations here)

Additional Comments

How many new units were added this year (Feb 1st 2016 to current date)? Leave at zero if no new units were added.

How many new units are currently under development? Leave at zero if no new units were added.
Additional Comments

Section III: Services Provided

Mortgage AssistanceStreet OutreachAlcohol & Drug AbuseEmploymentRental AssistanceMobile ClinicMental Health CounselingChild CareUtilities AssistanceLaw EnforcementHealthcareTransportationCounseling / AdvocacyCase Management HIV / AIDSFood ServicesLegal AssistanceLife SkillsEducationTANFSocial Security Insurance (SSI)SSDISNAP/Food StampsSubstance Abuse ProgramsMedicaidPrivate/Subsidized Health Ins.Educational ServicesMedicare

Section IV: Organization Coordinated Assessment Satisfaction Survey

Responses will be used for the improvement of the CoC's Coordinated Assessment System only, and will not affect funding or performance evaluations for the responding agency.

If yes, was the overall experience satisfactory for your agency and client(s)? Explain.

If not, why did you not refer or receive clients?