Gateway Center Visitor Entry Form

Obtain consent before completing this form
Ask:  "Can I keep some of your information (like your name and date of birth) in the Gateway Center database?"
If they opt out, please indicate they opted out of Salesforce on the navigator call log.
Additional information if requested:
"we collect information in order to make referrals and understand how to best serve you. It will also create a record that you accessed our services if you need the proof of it in the future. I will help you either way. If you say yes, your information will be visible to a small handful of Multnomah County employees. I can provide you with the names of those employees if it helps you decide." (Karina Rutova, Amanda Lee, Scott MacNeill, Kara Sydnor, Michelle Whitlock, Tricia Dreixler, Macy Wickline, Lakshmi Pasam, Kathy Trippy, Stephanie Smith).
Advocate Information

Select your name from the list. If your name is not listed, select 'Not Listed - Type In' and you can enter your name in the next field.


Visitor Information



MM/DD/YYYY


Please enter numbers only i.e. 5031234567

Please enter numbers only i.e. 5031234567











Gift card can only be offered if Survivor is impacted by COVID


Visit Information

MM/DD/YYYY









Please verify current contact information prior to submitting this form
Referral Information
Automated Referrals







YWCA HF INFORMATION











MM/DD/YYYY






Economic Empowerment Program
Economic Empowerment Program




Referral to Ongoing Advocacy Services

Mailing Address




File Attachments