santa cruz county housing for health partnership
211 Santa Cruz County is associated with various services and supports that can help people experiencing homelessness. Despite these connections, there are very limited housing and shelter resources available in Santa Cruz County, and not everyone seeking a housing resource can immediately receive one.
211 Santa Cruz County, in partnership with the County’s Housing for Health Division, is here to help link people to available supports and help identify potential resources for housing and other needs.
For any questions regarding the connection services request form please reach out to 211scc@unitedwaysc.org
Check out our SLE, Interim Shelters, and Low-Cost Rental Units

If you or someone you know is experiencing homelessness and not working with a Connector, submit this request form for Connection Services. This will allow 211 Santa Cruz County to review the household’s situation, determine available support, and provide resource recommendations. It may also help connect you to a Coordinated Entry Connector for further assessment, depending on availability.

Important: Provide detailed contact information and ensure to complete entire form.

This form is not a Coordinated Entry Assessment and does not place you on the housing queue.

Connection Services Request Form

Participant Information

Name
Name
First
Last
Is it okay if we send texts?
Location Currently Staying (provide enough information for a service provider to find you)
Location Currently Staying (provide enough information for a service provider to find you)
Street Address
Apt, Suite, #
City
State/Province
Zip/Postal
Please be as specific as possible
County Location
Race and Ethnicity

Provider Information

(If form is completed by Provider, or if participant has a provider they would like to have contacted.)

Name
Name
First
Last
Are you submitting on behalf of participant?

Contact #1

(Please provide information on someone who is likely to be able to reach you or know where you are)

Name
Name
First
Last

Contact #2

(Please provide information on someone who is likely to be able to reach you or know where you are)

Name
Name
First
Last
Services Desired
Are you currently receiving CalWORKs?
Interested in Safe Sleeping Options
Seeking safe parking
Participant has

Section 1: Household Composition

If you prefer not to answer any question, please leave blank.

A household is the adults and children that you live with or plan to live with when you have housing
4. Are other adult members of your household 65 or older?
5. Are you or any other members of your household currently pregnant?
6. Are you or any other members of your household between ages 18 and 24?
a. Did you/they ever receive foster care services?
7. Are you or any other members of your household a veteran of the US Armed Forces or was anyone ever on active duty in the military?
8. Some housing assistance is only for families with specific child welfare interactions. Do you or your family have an open child welfare case?
For example, are you seeking reunification of a child that has been removed from your custody by Child Welfare (County Family and Children’s Services) or are you currently under review for having a child removed?
9. Some shelters and housing assistance is only for people fleeing domestic violence. Are you fleeing or attempting to flee partner violence or other unsafe or violent situation?

Section 2: Housing History

Section 3: Health

If you prefer not to answer any question, please leave blank.

14. Do you have any disabilities or chronic health conditions that make it hard for you to secure housing:
(e.g., physical disability, developmental disability, chronic health condition, HIV-AIDS, mental health disorder or substance use disorder)
15. Do you need help with activities like bathing, feeding, cleaning?