Initial Contact Form

INITIAL CONTACT FORM
Attention:

Family Promise of Anderson County services families (adult(s) with legal custody of school age children (under 18).
Date

MonthDayYear
Date
First Adult's Name*

First NameLast Name
Second Adult's Name

First NameLast Name
Age:*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Are you at risk of being homeless?*

YesNo
Eviction?*

YesNo
Eviction date:

MonthDayYear
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

CityState / Province

Postal / Zip Code
Family Composition:*

Single-parent FemaleSingle-parent MaleTwo-parent Family UnmarriedTwo-parent Family MarriedSingle Female No ChildrenOther
Family Size*
Children ages:*
Current Living Situation:*
Employed:*

YesNo
Are you employed full-time now:

YesNo
If not, is there any reason you cannot work full-time?

YesNo
If not, are you willing and able to obtain employment?*

YesNo
Are you pregnant?*

YesNo
Domestic violence*

Yes, recentYes, not recentNo
Do you have an open CPS case?*

YesNo
Do you have transportation?*

YesNo
Should be Empty:

INITIAL CONTACT FORM