Are you in need of shelter or services? Please complete the intake form below. We receive a high volume of applicants and have very few openings in our shelter. If you have any questions, please call our office: (978) 922-0787 LEAD APPLICANT INFORMATION Please complete entirely. Name (Head of Household) * First Last Email Address Phone * Most Recent Address Address Line 1 Address Line 2 City * State * Zip Code Country Gender Identity * i.e. Male, Female, Non-Binary, Transgender, N/A... Date of Birth * Social Security Number Racial or Ethnic Identity * Black/African-American Hispanic/Latinx Asian American Indian/Alaskan Native Pacific Islander White/Caucasian Some other race(s) not listed Other Please select all that apply. Are you a US Veteran? Yes No What services are you seeking from Family Promise? Check all that apply. * Emergency Shelter Housing Advocacy (i.e. eviction prevention) Case Management (i.e. help with applications) Other Current Housing Situation * — Select — Renting Hotel/Motel Friends/Family Vehicle/Outdoors Emergency Shelter Other Are you currently facing eviction or foreclosure? * Yes No Unsure Reason for homelessness? * Eviction/foreclosure due to non-payment Domestic Violence Habitat unsuitable for living (i.e. mold, lead, asbestos) No longer able to live with friends/family Fire/Flood/Natural Disaster Not yet homeless Other Briefly describe the events that lead to homelessness... Income/Benefits (Check all that apply) * Employment SSI/SSDI Unemployment Benefits Child Support TANF/TAFDC Retirement SNAP (Food Stamps) Other None Approximate Monthly Income * Including yourself, how many members of your household need shelter? * SECOND ADULT INFORMATION Please list information of second adult also seeking assistance... Is there a second adult in the household? * Yes No Full Name First Last Email Address Phone Gender Identity i.e. Male, Female, Non-Binary, Transgender, N/A... Date of Birth Social Security Number Is the second adult a parent or legal guardian of any of the children listed? Yes No Other Income/Benefits (Check all that apply) Employment SSI/SSDI Unemployment Benefits Child Support TANF/TAFDC Retirement SNAP (Food Stamps) Other None Approximate Monthly Income CHILDREN Please provide information regarding your children... List Children: * Name, Date of Birth, Gender Identity (i.e. Male, Female, Non-Binary...) Are any of the children in school or daycare? * Yes No Other List Names and Locations of Schools/Daycares: i.e. "Briscoe Middle School, Beverly MA." OTHER INFORMATION Please provide some additional information to help us provide the best assistance. Do you have a vehicle? * Yes No Does everyone in the household have health insurance? * Yes No Do you or any adult member of your household have a criminal history? * Arrest Conviction Probation/Parole Pending Charges Other - Not listed No Criminal History Please note that our shelter is a low-barrier program. Having a criminal history will not prevent admission to the program. However, failure to answer this question and omission of details could lead to future discharge from the program. Does any member of your household have a history with substance abuse? * Yes No Other If yes, how long have they been sober? How many months of sobriety? (If less than one month, just put "1") Do you have any pets? * Yes No If yes, please specify: i.e. "One dog, two cats." How did you hear about Family Promise North Shore Boston? 211 Department of Transitional Assistance (DTA) Google Search Other Social Service Agency Social Security Administration Social Media Church, Temple, or Faith-Based Organization Friend/Family Other Is there any other critical information that you would like us to know about your family and your current situation?