Assessment for Program Eligibility

Assessment for Program Eligibility

All information entered is secure and confidential.
Answer each question below to the best of your ability. Once submitted, your assessment form will be digitally transfered to Family Promise of Essex County's Social Services team for review. A case worker from Family Promise of Essex County will contact you via phone and/or email once your assessment is reviewed to collect any additional information necessary. You will then be prompted to provide documentation (e.g., banking information, identification, proof of hardship, etc.) to support your answers to the questions below. Family Promise of Essex County case workers will work with you during the document collection process and, if found eligibile for services, you will be scheduled for an in-person appointment to complete an application for program enrollment.

If you are not eligibile for services or if Family Promise of Essex County does not currently have funding to assist your family, we will provide you will referrals to other agencies that may be able to assist you promptly.

We look forward to working with you!
What type of assistance are you seeking? (Check all that apply.)

Emergency Shelter for my family and meEmergency Shelter for just meRental Arrears AssistanceSecurity Deposit (Relocation) AssistanceUtility Arrears AssistanceI'm not sureOther
Name

First NameLast Name
Email
example@example.com
Phone number
Please enter a valid phone number.
Current address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you been residing at this current address?
Address you are moving to (for relocation assistance only)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your scheduled move-in date for this new address?

MonthDayYear
Date
What best describes your current housing situation?

I rent an apartment from a private landlord or management company.I rent a room.I own my home.I am currently homeless.I am paying out of pocket to stay in a hotel.An agency is paying for me to stay in a hotel.I am temporarily staying with family or friends.Other.
If seeking shelter or housing, where did you sleep last night?
If seeking financial assistance for rental arrears, security deposit, or utility assistance, what caused you to fall behind or not be able to pay?
If seeking security deposit assistance, why is your current security deposit not being returned to you?
How many adults (18 years or older) live in your household?
How many children (17 years old or younger) live in your household?
Are you currently pregnant?

YesNo
If you have an eviction notice, what is your court date?

MonthDayYear
Date
Do you have a current & valid photo ID with an Essex County address?

YesNo
What type(s) of income currently support your household? (Check ALL that apply.) You must include ALL income, including any income received by a minor in your household.

Employment IncomeUnemployment IncomeSSISSDISocial Security RetirementSocial Security Survivor's BenefitsChild SupportWorkman's CompensationPrivate DisabilityTemporary Assistance for Needy Families (TANF)General Assistance (GA)AlimonyOtherWe currently have no income in our household
What is your current total household income per month? Include income from all household members and all sources checked off above.
Are you a subsidized housing participant?

NoYes, I currently have a Housing Choice Voucher (Section 8).Yes, I was just awarded a Housing Choice Voucher (Section 8).Yes, I reside in an income-based apartment unit.Yes, I have been approved to move into an income-based apartment unit.Yes, I have another type of housing voucher or support (i.e., Rapid Rehousing, Temporary Rental Assistance, etc.)I'm not sure.
How much is your monthly base rent? (Do not include pet fees, parking fees, utility costs, or other fees.)
How many months are you behind in rent?
If you are behind in rent or utility payments, what is the total amount you owe to your landlord or utility provider?
What other agencies have you applied to for assistance in the last 12 months and what was the outcome? (Include how much financial assistance you received or information about a denial for assistance.)
How do you plan to keep up with rent, utilities, or other housing expenses moving forward?
Has your household been impacted by Covid-19 in any of the following ways? Check all that apply.

Significant loss of household income during the Covid-19 Pandemic.Increased necessary out of pocket expenses related to performing essential work or related to health impacts during the Covid-19 Pandemic.Increased costs for dependent care or to care for a family member diagnosed with Covid-19.Vacating current housing would pose a significant health risk because someone in my household has an increased risk for severe illness or death from Covid-19I have lost household income due to reduced hours or job loss due to my employer's regulations related to Covid-19Other circumstances related to the Covid-19 pandemic
By submitting this form, you understand that you are requesting to be assessed for program eligibility and that your eligibility is determined by guidelines set forth by grant funders. You understand that applications for assistance are assessed on a first-come, first-served basis.

All information included in this assessment will be protected by Family Promise of Essex County and is for informational purposes only. You agree to share all information included in this assessment with Family Promise of Essex County to determine your program eligibility by submitting this form.

If you are experiencing an immediate housing crisis or do not have a place to sleep tonight, please contact our office by phone at 973-746-1400 between 9am-5pm, Monday through Friday or 2-1-1 at any time during any day.
I have read, understand, and agree to the information sharing agreement above.*

Yes
Client Non discrimination Policy

Family Promise of Essex County (FPE) is an equal-opportunity organization. FPE prohibits discrimination and harassment based on race, color, creed, religion, sex, gender, national origin, citizenship, ethnicity, marital status, age, disability, sexual orientation, gender identity and gender expression, veteran status, or any other status protected by applicable law to the extent prohibited by law. The agency provides an atmosphere of respect, dignity, acceptance and safety for all clients. This nondiscrimination policy covers admissions, employment, and access to and the process of receiving shelter, housing assistance and case management services. Furthermore, no client will be discriminated against based on referral source. FPE is open to clients from a number of referral sources including, but not limited to, self-referrals, other social service agencies, schools, and local police departments.
I have read, understand, and agree to the Non discrimination Policy above.*

Yes
How did you hear about our agency? (Check all that apply)

NJ 2-1-1Friend or family memberMy landlordFPE has helped me the pastToni's Kitchen MontclairOther (Specify below)
If you selected "other", please specify:
Please verify that you are human*
Should be Empty: