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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 Data.

Are you experiencing homelessness? If so, please fill out this survey to be added to the County of Renfrew’s By-Name Data. The County of Renfrew’s By-Name Data 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. Later in this survey we will ask you provide consent to share the information your provided in this survey. By providing your consent to share information about your circumstances with our community partners, we may be able to connect you to services more quickly and we can work together with other support agencies to find housing or other resources.

You can still receive services, even if you do not consent to having your information shared with other service providers. If you would like help to complete this form, please call 1-866-897-4849.

Date of Completion:

Client Information

First Name:

Last Name:

Preferred Name (Alias):

Date of Birth:

Phone Number:

E-mail: