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 full, but we are accepting waitlist applications.

 

Interagency Referral Form

  • Family Information

    Please provide the following information about the family you are referring to Family Promise North Shore Boston.
  • Please do not proceed if you are unable to make this selection.
  • 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 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.
  • Include anyone in your household who is 19 years and above.
  • 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.
  • If pregnant, please count as 1 child in this category.
  • 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.
  • 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.
  • Please note that unfortunately our funding cannot typically cover hotel stays.
  • 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.
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