Interagency Referral Form

Please complete the form below to submit an intake to Family Promise North Shore Boston on behalf of the family you are referring.

Please note this form is for referring agencies only. If you are a family in need of assistance, please complete the form on the Need Help? page.

Please note that our services are only available for families with at least 1 adult and at least 1 child under the age of 18. Our shelter is currently closed and not able to accept waitlist applications at this time.

PLEASE NOTE: All of our programs are at capacity as of 9/14/23. Families filling out this form after 9/14/23 will be added to our waitlist for a call back as spots open up within our programs.

Interagency Referral Form

Family Information

Please provide the following information about the family you are referring to Family Promise North Shore Boston.
Name of Head of Household (HoH) *

First

Last
HoH Phone Number
HoH Email Address
HoH Current City and State *
Please confirm that this referral is for a family with at least 1 minor child. *

The household has at least one adult and one dependent (age 18 or under) or has a pregnant adult. Please do not proceed if you are unable to make this selection.
Please confirm that the referring agency has the HoH's permission to make this referral to Family Promise North Shore Boston. *

I have the head of household's permission to make this referral to FPNSB. Please do not proceed if you are unable to make this selection. If you have a general question about FPNSB services, please contact katie@familypromisensb.org or leave a message at 978-922-0787 ext 1.
Please describe the family's current situation of homelessness or housing instability. *

Please include primary reason(s) leading up to situation of homelessness/housing instability and where the family lives (e.g. rents their own home or stays longterm with a family member/friend) or, if experiencing homelessness, where they have been staying at night and for how long.
Including head of household, how many adults are in the household? *

Include anyone in your household who is 19 years and above.
Please list date of birth, race(s), ethnicity (i.e. Hispanic/Latine or Not Hispanic/Latine), and gender identity for each adult in the household. *

Providing this information is is optional; if you prefer not to answer write "prefer not to answer." This information (and your decision about whether to provide it) will not be used to determine eligibility for services.
How many children are in the household? *

If pregnant, please count as 1 child in this category.
Please list age, race(s), ethnicity (i.e. Hispanic/Latine or Not Hispanic/Latine), and gender identity for each child in the household. *

Providing this information is optional; if you prefer not to answer write "prefer not to answer." If you or someone in your household is pregnant, you can include how many weeks pregnant in this section. This information (and your decision about whether to provide it) will not be used to determine eligibility for services.
Please select all of the household's current sources of income. *

Employment Unemployment insurance TAFDC/EAEDC SSI/SSDI Child support Alimony Other
What is the household's total pre-tax income for this current month? *

Include all cash sources like wages, unemployment insurance, cash assistance, SSI/SSDI, child support, alimony, etc. but do not include food support, WIC, fuel assistance, or other non-cash benefits.
Referring Agency Information

Please provide the following information about the referring agency and contact person.
Name of Referring Agency *
Name of Referring Agency Contact Person

First

Last
Agency Contact Person Phone Number
Agency Contact Person Email Address
Please select the primary reason(s) for this referral: *

Family needs shelter Family needs up to $2000 in flexible financial assistance to keep or obtain permanent housing Family needs up to $2000 in flexible financial assistance to keep or obtain temporary housing Family needs wrap around case management to stabilize in permanent or temporary housing Family needs assistance applying for additional financial assistance to keep or obtain permanent housing Family needs assistance applying for subsidized housing and housing voucher programs Family needs assistance applying for affordable housing programs and has the ability to financially sustain an affordable housing unit Family needs assistance applying for market rate housing and has the ability to financially sustain a market-rate unit Other Unsure Please note that unfortunately our funding cannot typically cover hotel stays.
At this time, the family I am referring to FPNSB... *
The referring agency has assisted or plans to assist the family with the following shelter/housing-related services (please select all that apply):

Applied for Emergency Assistance through DHCD Applied for RAFT or ERAP Completed or updated subsidized housing and housing voucher applications (CHAMP, Section 8, MRVP) Started a market-rate or affordable housing search Provided a shelter stay Paid for a hotel stay Provided financial assistance related to housing stability Case management in other areas that impact housing stability (e.g. mental health care; job training; life skills) Other housing-related assistance not listed (please describe below)
Please provide any relevant details/updates about: 1) the service(s) selected in the previous question and/or 2) why the family did not qualify or no longer qualifies for shelter/housing-related services available at the referring agency.

Some examples: family was denied EA for X reason; family's financial need is greater than our cap of $X and we are looking for supplemental funding sources; the family did not meet our program criteria for X reason; our agency does not typically offer this particular type of assistance
Is there anything else FPNSB needs to know in order to best assist this family?
To follow up on this referral, FPSNB staff should... *

contact the family only and not follow up with referring agency contact the family first but may reach out to the referring agency/contact person as needed follow up with the referring agency/contact person first before reaching out to the family directly If selecting option 1 or 2, please make sure family contact information is provided above. If selecting option 2 or 3, please make sure the referring agency contact person & info has been provided above.