HMIS Services Request Form

HMIS Services Request Form

Please complete the form in its entirety in order to set up or make changes to program services in HMIS. When completed, please click submit. Thank you!
Completed by HMIS Admin

First NameLast Name
Date

MonthDayYear
Date
Are you a new agency that has never submitted a List of Services request before?
HMIS Housing Forward Agencies *
Add New Agency Name Below
Are you adding or deleting services?*
Add Services

After School CareBed NightBreathalyzerBus PassCare CoordinationCase ManagementChild CareChild Care ReferralClient TransportClothingCommunity Courts ReferralCommunity ServiceCommunity Service ReferralComputer Lab AccessCounseling ReferralCriminal Justice ReferralCritical Document AssistanceCritical Document ReferralDay CampDay ShelterDental CareDental Care ReferralDiversion - AttemptedDiversion - SuccessfulDomestic Violence EducationDrug TestEducation ClassEducation ReferralEmployment Assistance/SupportFollow UpFood Assistance/MealsFood Pantry ReferralFood VoucherFurniture AssistanceGas CardGED InstructionGED ReferralGift CardGrievanceGroup CounselingHome VisitHomeless PreventionHomeless Recovery GroupHotel/Motel VoucherHousehold ItemsHousing InspectionHousing ReferralHousing ServicesHousing StabilizationHygiene/Grooming SuppliesIndividual CounselingIntake and AssessmentJob ReadinessJob Placement-PermanentJob Placement-TemporaryJob Skills TrainingJob Search AssistanceJob TrainingJob Training ReferralLanguage Translation AssistanceLaundry AssistanceLeasing AssistanceLegal Assistance/ServicesLegal CounselingLegal Services ReferralLife Skills Group/ClassLife Skills ReferralLife Skills TrainingMail ServicesMainstream Benefits AssistanceMentoringMaintenance Request/AssistanceMedical ServiceMedical Service ReferralMedical SuppliesMedication DeliveryMedication ManagementMental Health CareMental Health ReferralMobile ClinicMortgage AssistanceNo ShowOrientationOutreachOvernight PassParenting Class/ Group ReferralParenting Class/GroupPetty CashPost-Employment ServicesPre-Employment ServicesProgram FeesRecertification ReferralsRental ArrearsRental AssistanceReunificationSack LunchShelter ReferralShowerSkills TrainingStreet OutreachSubstance Abuse ReferralSubstance Abuse CounselingSubstance Abuse TreatmentTherapeutic Group ReferralThrift Store VoucherTransportation AssistanceTuition AssistanceTutoring ReferralTutoring ServicesUtility ArrearsUtility AssistanceVeteran ServicesVeteran Services ReferralVision CareVision Care ReferralWarningWeekend PassWelcome Basket/Care PackageYouth ResourceOther
Add Other Services
Delete Services

After School CareBed NightBreathalyzerBus PassCare CoordinationCase ManagementChild CareChild Care ReferraClient TransportClothingCommunity Courts ReferralCommunity ServiceCommunity Service ReferralComputer Lab AccessCounseling ReferralCriminal Justice ReferralCritical Document AssistanceCritical Document ReferralDay CampDay ShelterDental CareDental Care ReferralDiversion - AttemptedDiversion - SuccessfulDomestic Violence EducationDrug TestEducation ClassEducation ReferralEmployment Assistance/SupportFollow UpFood Assistance/MealsFood Pantry ReferralFood VoucherFurniture AssistanceGas CardGED InstructionGED ReferralGift CardGrievanceGroup CounselingHome VisitHomeless PreventionHomeless Recovery GroupHotel/Motel VoucherHousehold ItemsHousing InspectionHousing ReferralHousing ServicesHousing StabilizationHygiene/Grooming SuppliesIndividual CounselingIntake and AssessmentJob ReadinessJob Placement-PermanentJob Placement-TemporaryJob Skills TrainingJob Search AssistanceJob TrainingJob Training ReferralLanguage Translation AssistanceLaundry AssistanceLeasing AssistanceLegal Assistance/ServicesLegal CounselingLegal Services ReferralLife Skills Group/ClassLife Skills ReferralLife Skills TrainingMail ServicesMainstream Benefits AssistanceMentoringMaintenance Request/AssistanceMedical ServiceMedical Service ReferralMedical SuppliesMedication DeliveryMedication ManagementMental Health CareMental Health ReferralMobile ClinicMortgage AssistanceNo ShowOrientationOutreachOvernight PassParenting Class/ Group ReferralParenting Class/GroupPetty CashPost-Employment ServicesPre-Employment ServicesProgram FeesRecertification ReferralsRental ArrearsRental AssistanceReunificationSack LunchShelter ReferralShowerSkills TrainingStreet OutreachSubstance Abuse ReferralSubstance Abuse CounselingSubstance Abuse TreatmentTherapeutic Group ReferralThrift Store VoucherTransportation AssistanceTuition AssistanceTutoring ReferralTutoring ServicesUtility ArrearsUtility AssistanceVeteran ServicesVeteran Services ReferralVision CareVision Care ReferralWarningWeekend PassWelcome Basket/Care PackageYouth ResourceOther
Delete Other Services
Other Services, List Them Here
Agency Data Quality Officer Name*
Email
example@example.com
Agency Data Quality Officer Signature

Clear
Date

MonthDayYear
Date
Should be Empty: