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) *
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. *
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. *
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. *
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
Agency Contact Person Phone Number
Agency Contact Person Email Address
Please select the primary reason(s) for this referral: *
Please note that unfortunately our funding cannot typically cover hotel stays.
At this time, the family I am referring to FPNSB... *
— Select One —
plans to continue to participate in services/programs at the referring agency
has exhausted or will soon exhaust the services/programs at the referring agency
is still in the intake process with the referring agency
was not eligible for any services/programs through the referring agency
The referring agency has assisted or plans to assist the family with the following shelter/housing-related services (please select all that apply):
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... *
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.
