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Homelessness By-Name Survey

Complete this form to add an individual or family to the County of Renfrew's By-Name List.

Are you experiencing homelessness? If so, please fill out this form to be added to the County of Renfrew’s By-Name List. The County of Renfrew’s By-Name List is a real time list of all known people experiencing homelessness within our community. Its aim is to reduce homelessness by increasing community collaboration, service coordination and access to services.

Please note that with your consent, the information reported on this survey may be shared with our By-Name List community partners for the purpose of providing appropriate referrals and further supporting you to finding housing resources that best match your circumstances. At the end of the survey, you will have an opportunity to provide your consent allowing us to share your information. If you have any questions or concerns, we welcome you to contact our office at 1-866-897-4849.

Staff Completing Intake Form:

Last Contact Date:

Date of Completion:

Client Information

Client's Last Name:

Client's First Name:

Client's Preferred Name (Alias):

Date of Birth:

Phone Number:

E-mail:

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Homelessness By-Name Survey

Client Information