TFH Client Registration

Email
example@example.com
First and Last Name
Phone Number
Format: (000) 000-0000.
Phone Number 2
Format: (000) 000-0000.
Home Address
City
State
Zip Code
DOB
Gender

FemaleMaleTransgenderUnspecified
Race
Type a question
11. Which of our programs are you interested in?*

HOPE: Homelessness Outreach, Prevention, and Education ProgramEmpowering Parents ProgramCommunity Resource Connection
What type of services are you seeking?

Housing AssistanceFood and NutritionJob Training/Employment ServicesChildcare ServicesMedical CareMental Health ServicesSubstance Abuse TreatmentLegal AssistanceEducational ServicesOther
Are there any immediate needs or concerns you would like us to address?
Please provide information for an emergency contact (name, phone, relationship).
Are you currently experiencing homelessness?

YesNo
How long have you beeen experiencing homelessness?

Less than 1 month1-6 months6-12 monthsMore than 1 year
Previous Housing Situation

Owned HomeRented Home/ApartmentStaying With Friends or FamilyShelterOther
Are you a single parent?

YesNo
How many children are in the household?
How many people in the household are 0-3 years of age?
How many people in the household are under 3-17 years of age?
How many people in the household are 18 years of age or older?
How many people in the household are 65 years of age or older?
Which best describes your curreny housing situation? (Check all that apply)

MortgageRentLiving with Family/FriendsLiving in Shelter TemporarilyLiving in Long Term ShelterLiving in a Long Term Care FacilityOther
Do your children receive a free or reduced-price school lunch?

YesNoI don't know.
Are you currently employed?

YesNo
Employment Status

Employed full-timeEmployed part-timeUnemployedStudentRetired
Are you currently receiving any kind of financial/income assistance?

YesNo
17. If yes, please specify the type of assistance:- Government benefits- Unemployment benefits- Child support- Other (please specify):

Government benefitsUnemployment benefitsChild supportOther
Monthly Household Income

No incomeLess than $500$500-$1,000$1,000-$2,000More than $2,000
Approximate Annual Household Income

$0 to $19,999$20,000-$49,999$50,000-$89,999$90,000-$129,999$130,000-$149,000$150,000+
Please check "Yes" below if we have your permission to use your or your child(ren)'s photo publicly to promote the organizations services and impact in the community. Checking "Yes" below confirms that you understand that these images may be used in print publications, online publications, presentations, websites, and social media. Checking "Yes" below confirms that you understand that no royalty, fee, or other compensation shall become payable to me by reason.

YesNo
How did you hear about our organization?

Word of Mouth/Friend/Family MemberWebsiteFacebook/InstagramAnother OrganizationOther
32 If someone or organization referred you to apply, please tell us their name.
Is there anything else you think we should know?
How did you hear about this organization?

Word of Mouth / Friend / Family MemberFriendFamily MemberOrganizationOther
By signing below, I consent to the collection and use of my personal information for the purpose of receiving services from The Forgotten’s Hope. I understand that my information will be kept confidential and will only be used to provide the necessary support and assistance.
Signature
Date

MonthDayYear
Date
Thank you for taking the time to complete this questionnaire. Your responses will help us better serve you and meet your needs.
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