Event–None–2019 Home for the Holidays
First Name
Last Name
Phone Number
Email
Gender–None–MaleFemaleTransgender Male to FemaleTransgender Female to MalePrefer not to Say
RaceCaucasianAmerican Indian or Alaska NativeBlack or African AmericanAsianNative Hawaiian or Other Pacific IslanderVeteran Doesn’t KnowVeteran Refused
Household Composition–None–Single AdultTwo Parent FamilySingle ParentFamily with Minor ChildrenOther
Past Client
Date of Birth
Last Four
CountyAitkin CountyAnoka CountyBecker CountyBeltrami CountyBenton CountyBig Stone CountyBlue Earth CountyBrown CountyCarlton CountyCarver CountyCass CountyChippewa CountyChisago CountyClay CountyClearwater CountyCook CountyCottonwood CountyCrow Wing CountyDakota CountyDodge CountyDouglas CountyFaribault CountyFillmore CountyFreeborn CountyGoodhue CountyGrant CountyHennepin CountyHouston CountyHubbard CountyIsanti CountyItasca CountyJackson CountyKanabec CountyKandiyohi CountyKittson CountyKoochiching CountyLac qui Parle CountyLake CountyLake of the Woods CountyLe Sueur CountyLincoln CountyLyon CountyMahnomen CountyMarshall CountyMartin CountyMcLeod CountyMeeker CountyMille Lacs CountyMorrison CountyMower CountyMurray CountyNicollet CountyNobles CountyNorman CountyOlmsted CountyOtter Tail CountyPennington CountyPine CountyPipestone CountyPolk CountyPope CountyRamsey CountyRed Lake CountyRedwood CountyRenville CountyRice CountyRock CountyRoseau CountyScott CountySherburne CountySibley CountySt. Louis CountyStearns CountySteele CountyStevens CountySwift CountyTodd CountyTraverse CountyWabasha CountyWadena CountyWaseca CountyWashington CountyWatonwan CountyWilkin CountyWinona CountyWright CountyYellow Medicine County
Branch of ServiceArmyNavyMarinesAir ForceCoast GuardNational Guard/ Reserves W/ Federal Active Duty TimeNational Guard/Reserves Without Active Duty Time
Discharge Type–None–HonorableGeneral Under HonorableGeneral Other than HonorableBad Conduct (Special)Bad ConductDishonorableUncharacterizedUnknownStill Serving
Service Connected?–None–YesNo
Current Housing Situation:–None–Emergency shelter, including hotel or motel paid for with emergency shelter voucher (HUD)Hospital or other residential non-psychiatric medical facility (HUD)Jail, Prison or juvenile detention facility (HUD)Long-term care facility or nursing homePsychiatric hospital or other psychiatric facility (HUD)Substance abuse treatment facility or detox center (HUD)Hotel or Motel paid without emergency shelter voucherOwned by client, no ongoing housing subsidyOwned by client with ongoing housing subsidy (HUD)Permanent housing (other than RRH) for formerly homeless persons (HUD)Rental by client, no ongoing housing subsidy (HUD)Rental by client with VASH subsidy (HUD)Rental by client, with GPD TIP subsidy (HUD)Streets/Place not meant for HabitationClient refused (HUD)Client doesn’t know (HUD)Transitional housing for homeless persons (including homeless youth) (HUD)Staying or living in a family member’s room, apartment or housing (HUD)Residential project or halfway house with with no homeless criteria (HUD)Rental by client, with other ongoing housing subsidy (including RRH) (HUD)Safe Haven (HUD)Interim HousingTransitional Housing
