Street Outreach Report Form
Complete this Street Outreach Report Form to document details of your outreach encounter.
Report Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Outreach Worker Name
*
First Name
Last Name
Outreach Location
*
Time of Encounter
*
Hour Minutes
AM
PM
AM/PM Option
Number of People Contacted
*
General Needs Observed
*
Housing
Food/Water
Medical Care
Mental Health Support
Substance Use Services
Employment
Other
Assistance Provided
*
Information/Referrals
Food/Water Provided
Medical Supplies
Transportation Assistance
Shelter Placement
Other
Is Follow-Up Needed?
*
Yes
No
Next Follow-Up Date (if needed)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Notes
Submit Report
Should be Empty: