MAIN St Online Intake Forms

MAIN St Online Intake Forms

Referrals:

Important:

All New Guests must first report to the MAIN ST INTAKE CENTER, located at: St John Evangelical Lutheran Church Parish House (Basement)

75 East Main Street, Pottstown, PA 19465

Between 9:00 pm & 10:00 pm. (Do not report before this time!)

3 steps to Refer Someone for Shelter:

1. Download, Print & Sign Shelter Rules...

Shelter rules must be agreed to in order to be given shelter at this location.

The potential guest, must bring this completed form to the Intake Center.

2. Download, Print & Sign Medical Form...

Fill out this Medical Release Form as competely as possible.

The potential guest, must bring this completed form to the Intake Center.

3. Fill Out The ONLINE REFERRAL Form...

All fields are required. Fill out this Referral Form (Below) competely, and

select the Submit button to sent us your Guest Referral.

Referring Service Provider:
Referrer's Name:
Your Email:
Your Phone Number:
Person's name the referral is for:
SSN:
Year of Birth:
Are there any medical issues we should be aware of?
Case Management Assigned?
If Yes, Where?
Mental Heath Diagnosis:
Substance Abuse Issues: Yes
Drug of Choice:
Last Used:
Income Amount:
Income Source:
On Medical Assistance?
Has the Individual been continuously homeless for a year or more?
Has the individual had at least four episodes of homelessness in past three years?
Reason for homelessness:
Is the Individual disabled?
Marital Status:
Last Known Address:
County:
Your confidential notes, helping us care for this individual:

Please know, this information is confidential and is for statistical purposes.