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 collection 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 we collect your information, it will be visible to a small handful of Multnomah County employees who work at Gateway Center and support with IT for our database. If you would like to discuss any data privacy concerns, I can help you contact our program supervisor for more information. 
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











Please describe the disability type
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

Note: You must check the Disability box above for Disability Rights Oregon referrals










Include amount requested or describe other needs





Mailing Address




YWCA HF INFORMATION















MM/DD/YYYY
Additional DVERT fields












Note: at least one of the following fields should be Yes

Economic Empowerment Program

Economic Empowerment Program


Referral to Ongoing Advocacy Services

File Attachments