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Support Request
Finally Family Homes partners with college aged (18-26 years) young people in North West Los Angeles County to help them achieve lasting success. To learn more about Finally Family Homes, visit https://finallyfamilyhomes.org. If you or someone you know is interested in receiving services from Finally Family Homes, please submit the following information.
Who is filling out this form?
*
I'm filling it out for myself.
I'm filling it out on behalf of someone else.
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Self Referral Form
Please fill out the following information about yourself and who referred you here. If you have any questions or concerns you can email us at info@finallyfamilyhomes.org
Name
*
First Name
Last Name
Preferred Pronouns
*
What city do you live in?
*
In what cities do you work / go to school?
*
Your Date of Birth
*
-
Month
-
Day
Year
Date
Your Email
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Preferred Means of Communication
*
Calling
Texting
Emailing
A Bit More About You
It’s helpful for our organization to ask a few more questions about those who are interested in our services. This information has no impact on your involvement in our programs or what services are available to you, it just helps us communicate with our funders and supporters. Thank you!
What is your ethnicity? (select as many as apply)
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Multiracial or Bi-racial
I prefer not to answer this question.
What is your gender identity? (select as many as apply)
*
Female
Male
Transgender Female
Transgender Male
Genderqueer/Non-binary
I prefer not to answer this question.
What is your sexual orientation?
*
Gay
Lesbian
Heterosexual
Bisexual
Queer
I prefer not to answer this question.
How much schooling have you completed?
*
I have not completed high school.
I have graduated from high school or have my GED.
I have completed some technical/trade school.
I have graduated from technical/trade school.
I have completed some college or university.
I have graduated from college or university.
I prefer not to answer this question.
Are you currently employed?
Yes, full time
Yes, part time
No
Are you a veteran?
*
Yes
No
What is your current yearly income (a guess is fine)?
*
$0-$44,000
$44,001-$50,000
$50,001-$57,000
$57,001-$70,001
$70,001 or more
I prefer not to answer this question.
Do you have any dependents?
*
Yes
No
Do you currently have stable housing?
*
Yes
No
Unsure
Do you practice a particular faith or religion? If so, what do you practice?
*
How can we best support you?
*
I would like help with housing
I would like to be more connected with a supportive community
Other
Systems Involvement
Your responses will be kept confidential and are used to help us understand and support your need better.
Are you currently involved with the justice system (e.g., probation, parole)?
*
Yes
No
Decline to answer ( May exclude you from certain supports and programs)
Have you ever been involved with the justice system (e.g., arrested, detained, or served time)?
*
Yes
No
Decline to answer ( May exclude you from certain supports and programs)
Are you currently in foster care or under the care of a state agency?
*
Yes
No
Decline to answer ( May exclude you from certain supports and programs)
Have you ever been in the foster care system?
*
Yes
No
Decline to answer ( May exclude you from certain supports and programs)
Is there anything else about you that you think it's important for us to know?
Referring Party's Information
Please tell us who told you to connect with Finally Family Homes
Referring Party's Name
*
First Name
Last Name
Referring Party's Title
Agency Name
Referring Party's Phone Number
Please enter a valid phone number.
Referring Party's Email
example@example.com
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Referral Form
Please fill out the following information for the young adult you are referring. If you have any questions or concerns you can email us at info@finallyfamilyhomes.org
Young Adult's Name
*
First Name
Last Name
Young Adult’s Preferred Pronouns (select as many as apply)
*
She/Her
He/Him
They/Them
I prefer not to answer this question.
What city does the young adult live in?
*
What city does the young adult work / go to school?
*
Young Adult's Date of Birth
*
-
Month
-
Day
Year
Date
Young Adult's Email
*
example@example.com
Young Adult's Phone Number
*
Please enter a valid phone number.
Best way to reach them
*
Calling
Texting
Emailing
A Bit More About The Young Adult
It’s helpful for our organization to ask a few more questions about the young adults who are interested in our services. This information has no impact on the young adults’ involvement in our programs or what services are available to them, it just helps us communicate with our funders and supporters. Please answer these questions to the best of your ability, and thanks!
What is the young adult’s ethnicity? (select as many as apply)
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Middle Eastern or North African
White
Multiracial or Bi-racial
I prefer not to answer this question.
What is the young adult’s gender identity? (select as many as apply)
*
Female
Male
Transgender Female
Transgender Male
Genderqueer/Non-binary
I prefer not to answer this question.
What is the young adult’s sexual orientation?
*
Gay
Lesbian
Heterosexual
Bisexual
Queer
I do not know or prefer not to answer this question.
How much schooling has the young adult completed?
*
The young adult has not completed high school.
The young adult has graduated from high school or has their GED.
The young adult has completed some technical/trade school.
The young adult has graduated from technical/trade school.
The young adult has completed some college or university.
The young adult has graduated from college or university.
I prefer not to answer this question.
Is the young adult currently employed?
*
Yes, full time
Yes, part time
No
What is the young adult’s current yearly income (a guess is fine)?
*
$0-$44,000
$44,001-$50,000
$50,001-$57,000
$57,001-$70,001
$70,001 or more
I prefer not to answer this question.
Does the young adult have any dependents?
*
Yes
No
Is the young adult a veteran?
*
Yes
No
Does the young adult currently have stable housing?
*
Yes
No
Please share how we can best supoprt the youth.
*
Help with housing
More supportive connections
Other
Systems Involvement
Your responses will be kept confidential and are used to help us understand and support your need better.
Is the young adult currently involved with the justice system (e.g., probation, parole)?
*
Yes
No
Decline to answer ( May exclude you from certain supports and programs)
Has the young adult ever been involved with the justice system (e.g., arrested, detained, or served time)?
*
Yes
No
Decline to answer ( May exclude you from certain supports and programs)
Is the young adult currently in foster care or under the care of a state agency?
*
Yes
No
Decline to answer ( May exclude you from certain supports and programs)
has the young adult ever been in the foster care system?
*
Yes
No
Decline to answer ( May exclude you from certain supports and programs)
Is there anything else about this young adult you think it would be helpful for us to know?
Referring Information
Please tell us about you / the person who is referring this young adult to Finally Family Homes
Referring Party's Name
*
First Name
Last Name
Referring Party's Title
*
Agency Name
*
Referring Party's Phone Number
*
Please enter a valid phone number.
Referring Party's Email
*
example@example.com
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Thank you!
Thank you for filling out our Program Referral Form! We will be in contact with you shortly.
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