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

Household Pre-Screening and Referral Form
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The SBC Pathways to Housing Network is an independent, service provider-driven, web-based referral system created to facilitate more efficient and effective referrals and collaboration between housing and shelter resource providers in San Bernardino County.

The SBC Pathways to Housing Network seeks to establish a streamlined process for service provider partners to share consumer requests, client referrals and housing resource interventions for all households experiencing or at-risk to homelessness in San Bernardino County.

Referral requests submitted to Pathways to Housing are distributed to over two dozen Network partners for review and consideration of potential housing resource assistance. Providers with resources that may be of assistance are asked to follow-up with the consumer or referring provider and engage them in their screening/intake/application process as appropriate. We cannot guarantee that any of our participating partner will have an available resource at the time of submittal.


 
The SBC Pathways to Housing Household Pre-Screening and Referral Form is designed to collect the basic information needed for participating agencies to make a preliminary determination on potential options to connect people dealing with a housing crisis to available housing and shelter resources that best fit their needs.

The Household Pre-Screening and Referral Form should be completed by a service provider staff person or volunteer advocate upon encountering or when contacted by a household seeking assistance with a current housing crisis – whether experiencing or at-risk of becoming homeless.

If you are not a service provider but are instead a person seeking assistance with a housing crisis for yourself, please complete the Consumer Request for Referral Assistance at the following link:
https://pathwaysnetwork.typeform.com/to/LJwKWh

 
Pre-Screening Agency

 
Pre-Screening Agent

 
Pre-Screening Agent Phone #

 
Pre-Screening Agent e-mail address

 
Pre-Screening Date

 
I confirm that an adult member of the household identified herein has given verbal consent to share the following information with the Pathways to Housing Network partners?

     
 
Head of Household Name (optional)

 
Head of Household Gender


 
Head of Household Date of Birth

 
Household Contact Phone #

 
Household e-mail address

 
Household Status


 
Household Make-up

 
# of adults

 
# of children under 18 years old

 
Age(s) of children under 18 years old

 
Any pets in household?

 
Current Living Situation


 
If "literally homeless", where has this household been sleeping? (car, park, abandoned property, etc.)

 
How long in current living situation?

 
City/Community of residence/currently sleeping in?

 
In what region is the above city/community?


 
Household willing to consider housing options outside of region?

     
 
Household has a vehicle or regular transportation?

     
 
Monthly household income amount $

 
Source(s) of income (check all that apply)


 
Does household participate in CalWorks program in SB County? (if no, skip Q24)

     
 
If YES to CalWorks please respond to a or b below for direct referral to TAD housing resources (info below will not be shared with other Network partners)

 
TAD Case Number

 
Social Security Number

 
Subpopulation characteristics/vulnerabilities (check all that apply)


 
Please briefly describe this household's current or pending housing crisis.

 
Suggested/requested housing interventions?


 
If this referral is for an adult without children living on a fixed income, would they 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 might help with identifying referral options for this household.

 
Local School Districts offer services to families dealing with homeless and housing issues.

 
Do any children in household attend school in San Bernardino County?

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

 
Would this family like us to share their request for assistance with school district service staff?

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

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