INITIAL CONTACT FORM
Attention:
Family Promise of Anderson County services families (adult(s) with legal custody of school age children (under 18).
Date
-
Month
-
Day
Year
Date
First Adult's Name
*
First Name
Last Name
Second Adult's Name
First Name
Last Name
Age:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Are you at risk of being homeless?
*
Yes
No
Eviction?
*
Yes
No
Eviction date:
-
Month
-
Day
Year
Date
Other reason for homelessness
Where did you stay last night?
*
How long have you been in your most recent residence?
*
Most Recent/Last Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Family Composition:
*
Single-parent Female
Single-parent Male
Two-parent Family Unmarried
Two-parent Family Married
Single Female No Children
Other
Family Size
*
Children ages:
*
Current Living Situation:
*
Employed:
*
Yes
No
Are you employed full-time now:
Yes
No
If not, is there any reason you cannot work full-time?
Yes
No
If not, are you willing and able to obtain employment?
*
Yes
No
Are you pregnant?
*
Yes
No
Domestic violence
*
Yes, recent
Yes, not recent
No
Do you have an open CPS case?
*
Yes
No
Do you have transportation?
*
Yes
No
Submit
Should be Empty: