Homeless Prevention and Diversion Services
Any information provided below are confidential and will not be shared with any other party.
Personal Information
Name
First Name
Last Name
Are you currently homeless?
Please Select
Yes
No
Phone
-
Area Code
Phone Number
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
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1929
1928
1927
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1924
1923
1922
1921
1920
Year
Email
example@example.com
Gender
Please Select
Male
Female
Transgender Male
Transgender Female
Queer Gender
Non-Binary
I do not want to answer this question
Ethnicity
Please Select
Hispanic
Black / African American
White
Native American
, Alaska Native, Indigenous
Native Hawaiian or Pacific Islander
Middle Eastern or North African
Asian or Asian American
Other
Marital Status
Please Select
Single
Married
Divorced
Widowed
Do you have an identification card?
Please Select
Yes
No
If so, for what state?
Identification Number
I am taking this questionnaire:
Online
Over the phone
In person
Other
Who is completing this form?
Self
Family member or friend
Faith Formula Worker
Other
What county are you in?
Dallas
Ellis
Collin
Tarrant
Other
Do you have children with you under the age of 18?
Please Select
Yes
No
Basic Information
To determine what services may be available for you, we will need to collect some basic information about your current situation. This information is confidential and will only be used to assist you in accessing appropriate resources. You may refuse to answer any questions, but doing so may mean you will not be referred to available resources that might best help you in your current situation.
How did you hear about Faith Formula Human Services?
Can we make referrals on your behalf to other agencies that may offer services that we are unable to accommodate?
Please Select
Yes
No
What specific services are you needing?
Rent / mortgage for a residence that you are currently residing in
Utilities
Shelter or immediate housing
Food
Clothing
Are you a veteran?
Please Select
Yes
No
Are you currently homeless (unhoused, staying in a shelter, fleeing a domestic violence situation, etc) or at risk of homelessness?
Please Select
Yes
No
Are you currently staying with family/friends?
Please Select
Yes
No
Are you currently staying in a hotel that you are or a relative/friend is paying for?
Please Select
Yes
No
Are you currently residing with or trying to leave an intimate partner who has made you fearful or has threatened you?
Please Select
Yes
No
Where did you sleep last night?
Are you currently working or receiving any forms of income?
Please Select
Yes
No
Is there any other information that you would like to share based on your situation that may be important for us to be aware of?
Submit
Should be Empty: