LAA _Gwinnett_Outreach_Center

LAA Gwinnett Outreach Center

Pre-screening Form
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

CityState / Province

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?*

Word of Mouth (Family & friends)LAA Internal ReferralSchool, College or UniversityGovernment AgencyInstagramFacebookLinkedInGoogle SearchLAA WebsiteRadioEmailExternal referralPrint advertising
Date of birthday*

MonthDayYear
Month-Day-Year
Gender*

FemaleMaleNon-binaryTransgender - MTFTransgender - FTMPrefer not to sayOther
Ethnicity*

Hispanic or LatinoNon-Hispanic or Latino
Race*

Mixed RaceWhiteAsianBlack or African AmericanNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderPrefer not to say
Country of Origin*
Do you have a Social Security Number?*

YesNo
What is your immigration status?*

US CitizenUS ResidentWork PermitNo Immigration StatusDecline to Answer
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
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

MonthDayYear
Date
Are you currently fleeing from Domestic Violence?*

YesNo
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?*

YesNo
Please call 911 immediately if you are in immediate danger.
Which of the following situations have you experienced? (Select all that apply)*

Intimate Partner ViolenceSexual AbuseDating ViolenceStalking
When did you last experience any of the situations you selected above?*

In the last 7 daysIn the last monthIn the last 6 monthsMore than 6 months ago
Are you open to domestic violence shelters?*

YesNo

LAA Gwinnett Outreach Center