Staff Forms Library

Admission Date: Admission Time:

Assigned Bed: Staff Completing Admission:

Legal Name: Preferred Name: DOB:

Adult Age Verification: ☐ 18 or older ☐ Referral needed because individual is not eligible for adult shelter

Current Sleeping Location: ☐ Street ☐ Vehicle ☐ Shelter ☐ Motel ☐ Hospital ☐ Jail Release ☐ Other

Immediate Needs: ☐ Food ☐ Shower ☐ Laundry ☐ Clothing ☐ Medical ☐ Housing ☐ Employment ☐ Identification ☐ Transportation

I acknowledge receiving information regarding guest rights, community standards, complaint process, emergency procedures, privacy practices, and available shelter services.

Guest Signature: Date:

I agree to treat others respectfully, refrain from violence and threats, respect staff and other guests, protect property, follow emergency instructions, and respect quiet hours.

Guest Signature: Staff Signature:

Guest Name: Assigned Bed:

Items: ☐ Backpack ☐ Suitcase ☐ Clothing ☐ Cell Phone ☐ Medication ☐ Wallet ☐ Other

Description:

Storage Bin/Locker:

Medical Emergency? ☐ Yes ☐ No   Behavioral Emergency? ☐ Yes ☐ No   EMS Needed? ☐ Yes ☐ No

Immediate safety concern:

Supervisor notified: ☐ Yes ☐ No

Date: Guest Name Optional:

Issue / Concern:

Requested Resolution:

Incident Number: Date/Time: Location:

Persons Involved:

Description of Incident:

Emergency Services Contacted: ☐ EMS ☐ Fire ☐ Law Enforcement ☐ None

Employee: Position: Hire Date:

Reviewed: ☐ Mission ☐ Housing First ☐ Trauma-Informed Care ☐ Confidentiality ☐ Boundaries ☐ Emergency Procedures ☐ Fire Safety ☐ Incident Reporting

Employee: Training Date: Instructor:

Topics: ☐ Orientation ☐ De-escalation ☐ Narcan ☐ CPR/First Aid ☐ Infection Prevention ☐ Documentation ☐ Customer Service

Reporting Month:

Occupancy: Admissions: Discharges: Housing Placements:

Executive Summary: