Out-Wayne County Coordinated Entry Community Referral Form

The following referral form is for use by Out-Wayne County Community Partners who want to refer individuals/families experiencing a housing crisis to housing resources.  Assistance from the referring partner may be needed and is suggested in completing the form. A member of the Coordinated Entry team will contact the household within 3 business days of receipt of the referral.


I (head of household) give permission to the community partner to refer for services related to housing assistance through the Out-Wayne Coordinated Entry process. This may include disclosing or obtaining contact information, homeless status, and other general information needed to assist in resolving my housing crisis.