LAA _Gwinnett_Outreach_Center_Prescreening
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  • LAA Gwinnett Outreach Center

    Pre-screening Form

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    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.

  • Format: (000) 000-0000.
  • Have you received services from the LAA or HomeFirst Gwinnett?*
  • How did you hear about this program / service?*
  • Date of birthday*
     - -
  • Gender*
  • Ethnicity*
  • Race*
  • Do you have a Social Security Number?*
  • What is your immigration status?*
  • Have you ever served in the U.S. Military?*
  • Did you serve at least one day on active duty, other than basic training OR were you medically discharged during basic training?*
  • Are you presently expecting a baby?*
  • Expected date of birth
     - -
  • Are you currently fleeing from Domestic Violence?*

  • Important Reminder:

    Please note that internet usage can be monitored and is impossible to erase completely. If you are concerned your internet usage may be monitored, call the National Domestic Violence Hotline at 800.799.SAFE (7233) or text "SAFE" to 88788. If you are in immediate danger, please also call 911.

  • Do you feel safe right now?*

  • Please call 911 immediately if you are in immediate danger.

  • Which of the following situations have you experienced? (Select all that apply)*
  • When did you last experience any of the situations you selected above?*
  • Are you open to domestic violence shelters?*
  • Where did you sleep last night?*
  • Do you live in Norcross/ Peachtree Corners?*
  • Have you been in the same city for at least the past 2 months?*
  • Are you, or any other adult in the household, currently employed?*
  • If the referral is available, which types of assistance are you willing to accept? Select all that apply. Not all options will be available due to limited capacity in Gwinnett County.*
  • Do you need help with accessing or obtaining any of the following? Select all that apply. This is used for data analysis and not all items can be provided in our community.*
  • To make sure we don't make a referral to an organization where you are not currently eligible to receive financial assistance, please select all of the organizations where you have received financial assistance within the last year. Select all that apply.*
  • Should be Empty: