top of page
People Looking at paperwork

Front Door 
Assessment Application

Front Door Assessment Application

Please fill out this form to the best of your ability. Don’t worry if you’re unable to answer some of these questions.

Front Door Assessment Services are currently unavailable. Please check back at a later date. 

Household Size
Are you literally homeless (living on the streets, living in a tent, living in a shelter, or living in another place not meant for habitation)?

3 Year Housing / Homelessness History

Please read the following statements before signing below. 

I certify through my signature below that all information reported to intake staff and entered into WellSky is true and correct to the best of my knowledge. I affirm that my address and the number of people in my household are true and accurate and that I will not sell, barter or trade food or items received.  ​ I understand Catholic Community Services (CCS) provides services through a variety of funding sources, may include government grants, public funds, or grants from private foundations, and that CCS is required to collect and report certain information to account for how these funds are used. This information may aid the effort to end homelessness by demonstrating how many individuals and families in the area need services. For this reason, I have been asked to provide my household information. The information I have provided will be entered into a Homeless Management Information System, WellSky, and used to provide statistical information about services provided to homeless persons (or persons at risk of homelessness) in Lane County and the Eugene/Springfield area. My identifying information will be kept as confidential as possible. I consent with my signature for the following to share information related to my application or provision of assistance: FOOD for Lane County FOODnet Providers, WellSky Participating Agencies, Persons who administer or Audit WellSky, CCS Program Funders, Auditors or their Designees. I understand I will be accorded and assured confidentiality within legal and professional norms.  ​ My signature indicates my understanding of my right to file a grievance if I feel I have been harmed in some way by the use of the computerized data system. Furthermore, if at any time I feel I have been treated unjustly or unfairly regarding the services I have received or believe I should have received from CCS, I may file a complaint using the process outlined in the posted CCS Grievance Policy. A copy of the Grievance Policy is available to me at my request. CCS is an equal ooportunity provider.

Consumer Rights, Responsibilities, and Grievance Procedures in the Coordinated Entry Process

The following list of rights and responsibilities does not presume to be all-inclusive, but is intended to show our concern for you and to emphasize the need for observance of these rights and responsibilities. 

Consumer Rights - You as the participant have the following rights: 

• Nondiscrimination and equal opportunity provisions of Federal civil rights laws, including the:

Fair Housing Act, Section 504 of the Rehabilitation Act, Title VI of the Civil Rights Act, Title II of the Americans with Disabilities Act, and Title III of the Americans with Disabilities Act

• Prohibits discriminatory housing practices based on race, color, religion, sex, national origin, disability, or familial status under any program or activity receiving Federal financial assistance.

• View, correct, or ask for a copy (fee may be associated) of the information in your record. 

• Obtain a copy of the ServicePoint privacy notice and disclosures of how your personal information will be shared.

• You may refuse to: consent to share your data, participate in the coordinated entry process or any of the housing services we provide, work with a housing program provider, or accept the housing offered to you. 

• File a grievance if you feel your rights have been violated. If your grievance is against:

Coordinated Entry Assessor who has completed the VI-SPDAT and Assessment with you - file a grievance with the agency. 

Housing Program Provider - file a grievance with the housing program.

Coordinated Entry Process, such as being denied entry to or removal from the housing waitlist - contact Steve Manela at 541-682-3797 or Steve.Manela@CO.Lane.OR.US to file a grievance.

Consumer Responsibilities - You as the participant agree to: 

• Follow up with the Coordinated Entry Assessor to check if you made the housing waitlist. 

• Keep your contact information current. You may call any agency on the back of this form to update your contact information. If after being referred to two housing programs and neither are able to contact you, you will be removed from the housing waitlist. 

• Make an appointment with a Coordinated Entry Assessor for a reassessment after waiting for housing for 6 months. You may contact any agency on the back of this form for the reassessment. You may refuse to be reassessed and will be removed from the housing waitlist. 

• Look into other housing opportunities. Wait times on the housing waitlist can be long. Put yourself on other housing waitlists (Ask your assessor for suggestions). If you have family or friends that can assist you, but they are out of the area, let your assessor know; we may be able to help you relocate. 

Click here to download Consumer Rights, Responsibilities, and Grievance Procedures PDF 

bottom of page