LAA_GOC_preescreening

Please be aware of scams and suspicious behavior. The Latin American Association and HomeFirst Gwinnett will never request money from you for services or assistance. If someone has requested money from you via Cash App, Venmo, PayPal, etc., in exchange for services or assistance, please report to the FTC at ReportFraud.ftc.gov. If you have fallen victim to a scam or fraud, you should file a police report.

All information provided in this application may be shared with partner agencies within the Gwinnett Coordinated Entry System for the purposes of providing services only. By submitting this application, you are affirming that the information you are providing is true and accurate.

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number. Fill with 0 if you do not have a phone

Email*

Leave the example email if you don't have an email

Zip Code*

Street Address

Street Address Line 2

Postal / Zip Code

CC - Email Silvia

example@example.com

codigo

Have you received services from the LAA or HomeFirst Gwinnett?*

No - New ClientYes - Returning Client

How did you hear about this program / service?*

Date of birthday*

Month-Day-Year

Gender*

Ethnicity*

Hispanic or LatinoNon-Hispanic or Latino

Race*

Country of Origin*

Do you have a Social Security Number?*

YesNo

English Proficiency

Have you ever served in the U.S. Military?*

YesNo

Did you serve at least one day on active duty, other than basic training OR were you medically discharged during basic training?*

YesNo

Have you ever been diagnosed with any mental health condition?*

YesNo

How many adults (18+), including yourself, will be in the household if we are able to provide emergency shelter?*

How many children (under 18) will be in the household if we are able to provide emergency shelter? Do not include children who will be living with someone else until and will only be living with you if you get PERMANENT housing*

Are you presently expecting a baby?*

YesNo

Expected date of birth

Date

Are you currently fleeing from Domestic Violence?*

YesNo

LAA Gwinnett Outreach Center