SBC PATHWAYS TO HOUSING NETWORK
A Collaborative Housing & Shelter Resource Referral Network

Consumer Request for Referral Assistance
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The SBC Pathways to Housing Network is a service provider-driven, web-based referral system established to develop a means to more quickly and efficiently match households in San Bernardino County that are experiencing or at-risk to homelessness with available housing and shelter resource providers that best fit their needs.

The Consumer Request for Referral Assistance is designed to collect the basic household profile information needed for participating agencies to make a preliminary determination on potential options to help connect your household to available housing and shelter resources in the county.

The SBC Pathways to Housing Network is not a service providing agency and does not directly provide any housing or shelter resources. We share consumer requests for assistance with over two dozen housing and shelter resource partners in hopes of connecting your household with available resources that meet your needs.

However, we cannot guarantee that any of our partners will have a resource to assist with your situation at this time and thus you may not receive a response to your request. We encourage you to continue to independently pursue all available options.

 
By providing your household information on the following web-based referral form, you are VOLUNTARILY CONSENTING to have the SBC Pathways to Housing Network share the information provided by you with any and all of our participating service provider partners in hopes of finding a solution to your housing situation. You are not required to respond to every question, however doing so will make it easier for us to identify all potential options for your household.

If you agree and wish to continue, please press the "I AGREE" button below.

 
Today's Date

 
First Name

 
Last Name

 
Contact Phone #

 
Gender


 
Date of Birth

 
Household Information

 
What is your household status?


 
How many adults in your household?

 
Do you have any pets in your household?

     
 
If yes to pets, please identify number and type(s)?

 
How many adults in your household?

 
How many children under 18 years old in your household?

 
What are the age(s) of the children under 18 years old in household?

 
Do you have any pets in your household?

     
 
If yes to pets, please identify number and type(s)?

 
Public School Districts offer services to households dealing with homeless and housing issues

 
Do you have children attending school in San Bernardino County?

     
 
if yes, in what school district? (or name of school and city)

 
Would you like us to share your request for assistance with school district service staff?

     
 
Current Living Situation

 
What is your current living situation?


 
How long in your current living situation?


 
Where might you go if you have to leave your current living situation?


 
If "literally homeless" (place not designated or ordinarily used for regular sleeping accommodations)

 
How long in your current living situation?


 
Where did you sleep last night?


 
Where will you sleep tonight?


 
Would you like to be contacted by a local homeless outreach team?

     
 
If yes, can you be reached by cell phone?

     
 
Please identify a good location where you might be found/contacted by outreach personnel during the day?

 
If staying in emergency shelter, short-term housing or institutional facility

 
How long in your current living situation?


 
By what date do you have to leave the current location?

 
Where might you go once you have to leave your current living situation?


 
If paying for hotel/motel with own resources

 
How long in your current living situation?


 
If unable to continue paying for motel, by what date do you have to leave?

 
Where might you go once you have to leave your current living situation?


 
If staying with family or friends

 
How long in your current living situation?


 
Do you have the option to remain in your current living situation until you can secure housing on your own?

     
 
If you have been asked to leave your current living situation, by what date are you expected to leave?

 
Where might you go if you have to leave your current living situation?


 
If facing loss of rental housing

 
How long in your current living situation?


 
Are you at imminent risk of losing your rental housing within the next 30 days?

     
 
Do you have the option to remain in your rental housing if the "risk situation" can be resolved?

     
 
If unable to remain in your current housing, by what date do you have to vacate?

 
Where might you go once you have to leave your current rental housing?


 
If fleeing/attempting to flee domestic abuse/intimate partner violence

 
How long in your current living situation?


 
Are you concerned about your safety at this time?

     
 
Are you currently in a safe place at this time?

     
 
Are you currently in need of a place to go to escape from active violence or abuse in your living situation?

     
 
Where might you go if you have to leave your current living situation?


 
Would you like to be contacted by a domestic violence service provider?

     
 
If yes, is it safe to contact you by phone?

     
 
If yes, is it safe to contact you by e-mail?

     
 
Current Location

 
In what city or community are you currently living/sleeping?

 
What is the zip code where you currently live/sleep?

 
Are you willing to consider shelter or housing options outside of the area where you currently live?

     
 
Do you have a vehicle or regular form of transportation?

     
 
Household Income

 
What is your monthly household income amount?

 
What is your source of income? (check all that apply)


 
If you receive Cash Aid from San Bernardino County and participate or are eligible for the CalWORKs program, we can refer you directly to a TAD housing resource specialist. Please provide your TAD case # and/or SSN (case#/SSN will not be shared with other Network partners)

 
Do you receive your Cash Aid from The County of San Bernardino?

     
 
Do you participate in the CalWORKs program in San Bernardino County?

     
 
TAD Case Number

 
Social Security Number

 
Current or pending housing crisis

 
Please briefly describe your current or pending housing crisis.

 
What has triggered your current or pending housing crisis?


 
Please identify your current obstacles to achieving stable housing?


 
What type of housing assistance are you seeking at this time?


 
There are a variety of housing and shelter resources available to assist families and/or individuals meeting specific characteristics. To help us try and identify all potential resources that might be available to assist you with your housing crisis, please respond to the following.

 
Please check all categories below that apply to you and/or members of your household:


 
If you are an adult without children living on a fixed income, would you like to consider housing options available through the SB County Peer Driven Room and Board Advisory Coalition?

     
 
Please provide any additional comments or information that you think might help with identifying referral options for your household.

 
What agency and/or person referred you to the Pathways to Housing Network?

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