Client Intake Form | Family Promise

LEAD APPLICANT INFORMATION (Head of Household)

Please complete entirely. Due to the high volume of applications and our shelter's size, not every applicant will receive a call-back.

Name (Head of Household) *

First

Last

Phone Number *

Email Address

Last Permanent Address

Address Line 1

Address Line 2

City *

State *

Zip Code

Country

Last place you've lived for longer than 6 months and/or where you last paid rent.

Gender Identity *

i.e. Male, Female, Non-Binary, Other, N/A...

Date of Birth *

Racial or Ethnic Identity *

Black/African-American Hispanic/Latinx Asian American Indian/Alaska Native Pacific Islander White/Caucasian Other Prefer not to answer Please select all that apply.

Income/Benefits (Check all that apply) *

Employment SSI/SSDI Unemployment Benefits Child Support TANF/TAFDC Retirement SNAP (Food Stamps) Other None

Approximate Monthly Income for Lead Applicant and Children *

Please include your income and any income received from children.

Employment Status *

Currently employed Not employed as of recently (within this last year) Have not been employed for over a year Have never been employed

Please describe your history of employment (types of jobs, reason for unemployment):

HOUSING SITUATION

Please tell us more about your current housing situation and needs.

Current Housing Situation *

What best describes the reason your family is experiencing homelessness, or is at risk of homelessness? *

Please provide a bit more detail about the events that led to your family’s homelessness or risk of homelessness… *

What town is your family from? *

Are you willing to relocate for a housing opportunity? (If yes or no, please elaborate) *

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

Phone Number

Email Address

Gender Identity

i.e. Male, Female, Non-Binary, Transgender, N/A...

Date of Birth

Racial or Ethnic Identity

Black/African-American Hispanic/Latinx Asian American Indian/Alaska Native Pacific Islander White/Caucasian Other Prefer not to answer Please select all that apply.

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

Employment Status

Currently employed Not employed as of recently (within this last year) Has not been employed for over a year Has never been employed

Please describe your history of employment (types of jobs, reason for unemployment):

Their Approximate Monthly Income

CHILDREN

Please provide information regarding your children...

List Children (Age, Gender Identity, Initials): *

Initials, Age, Gender Identity (i.e. Male, Female, Non-Binary...)

Are any of the children in school or daycare? *

Yes No Other

OTHER HOUSEHOLD INFORMATION

Please provide some additional information to help us provide the best assistance.

Total Household Monthly Income *

Please list the total amount of your household's income from all sources.

Do you have a vehicle? *

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 use disorder? *

Yes No Other

If yes, how many months 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?

Are you in need of shelter?

Please complete the Shelter Application below.

EMERGENCY SHELTER APPLICATION

LEAD APPLICANT INFORMATION (Head of Household)

HOUSING SITUATION

SECOND ADULT INFORMATION

CHILDREN

OTHER HOUSEHOLD INFORMATION