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2. If you are homeless and looking for ways to help you end homelessness, please complete this form and someone from the City's homeless task force will contact you to help. 

4. Are you currently homeless on the streets in the City of Lake Elsinore?

   1. Yes
   2. No
6. Where have you been staying? (i.e. cross streets)
8. Name
10. Where have been staying? (i.e. cross streets)
12. Contact Information

    Please enter the best way to reach you.

14. Phone Number (if applicable)
15. Email (if applicable)
17. Other contact information
19. Barriers Preventing You from Ending Homelessness

    1. Alcohol Use
    2. Drug Use
    3. PTSD
    4. Mental Health Conditions
    5. Physical Disabilities
    6. Developmental Disabilities
    7. Brain Injury
    8. Victim of Domestic Violence
    9. HIV / AIDS
    10. Jail (within 12 months)
    11. Other
20. If other, explain:

22. Thank you for taking the first step. We are eager to try to find the right partner who can help you address your needs and find a permanent place to call home. 

Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field