Homeless Management Information System (HMIS) New Participating Agency Interest Form

Please fill out this form if you are not currently a participating agency and are interested in becoming an HMIS participating agency. Once you submit this form you will hear back from a member of our HMIS team but if you have any questions while completing the form, please don’t hesitate to reach out to us at [email protected].

Agency Name

What is your name?

What is your role/title at your agency?

What is your email address?

Address

Address 2

City

State

ZIP Code

What kind of services does your agency provide?

What does the population of the people your agency/organization work with typically look like? (families, immigrants, individuals with mental health concerns, etc.)

Is your agency already connected with the CoC (Continuum of Care)?

Yes

No

I am unsure

Do you already partner or work closely with a current HMIS Participating Agency? If yes, which one?

Is your agency/organization a 501(c)(3) or nonprofit?

Yes

No

Why do you want to use HMIS?