CES Intake Form

Please complete as much information as possible and a Coordinated Entry Intake Specialist will return the persons call within 3-5 business days. 

Please inform callers that the Specialist will be continuing the conversation to better assist the caller to resolve their homelessness.

A call DOES NOT guarantee services.

Please refer to the intake call tree, all callers must be either: literally homeless or Veterans at risk of being homeless.

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Person’s Living Situation:
–None–Renting/Own Home – REFER OUT TO OTHER SERVICES STOP HERE, unless a VeteranLiterally Homeless – in shelter, sleeping in car, on streets, place not meant for habitationDoubled Up with Friends or Family – REFER OUT TO OTHER SERVICES STOP HERE, unless a Veteran

First Name


Last Name


Population Type:
–None–FamilyIndividualVeteran FamilyVeteran IndividualYouth (18 to 24)Youth Family

Email


Phone


Mobile


Agency Completing Request Form:–None–211 Specialist at Heart of Florida, United WayHSN – Veteran TeamHSN – CES TeamHSN – Admin\Office ManagerHSN – Other (HMIS, Grants, Fin, etc)Community Resource NetworkVA Provider

Internal Notes:

*** Please send all VA referrals to HSN Fax # 407-893-5299 with attention to Veteran Programs.