Family Promise of Juneau Intake Form

Family Promise of Juneau Intake Form
This intake form must be completed online or with an FPJ staff member before meeting with a case manager. Please note that completing this form does not guarantee eligibility for Family Promise of Juneau services.

Please note that the following must apply to you to be eligible for Emergency Shelter Services.
- The household must include at least one child under the age of 18.
- All household members must agree not to use drugs or alcohol at any FPJ site.
- No household member may have criminal charges related to sexual offenses, violence, or any charges involving harm or endangerment of a minor.
Today's Date

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Client Name (Adult) - Head of Household

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Gender

MaleFemaleNonbinaryOther
Race

American Indian or Alaska NativeAsianBlack or African AmericanHispanicLatinoNative Hawaiian or Pacific IslanderWhiteMultiracialOther
Do you have a tribal affiliation? If so please indicate your tribal affiliation.
Are you a military veteran?

YesNo
Source of Income

EmploymentSocial SecurityDisabilityUnemploymentOther
Total Income per Month
Current Employment Status

Employed Full-TimeEmployed Part-TimeUnemployedStudentRetiredOther
Occupation
Employer
Client Name (Adult)

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Date
Gender

MaleFemaleNonbinaryOther
Race

American Indian or Alaska NativeAsianBlack or African AmericanHispanicLatinoNative Hawaiian or Pacific IslanderWhiteMultiracialOther
Do you have a tribal affiliation? If so please indicate your tribal affiliation.
Are you a military veteran?

YesNo
Source of Income

EmploymentSocial SecurityDisabilityUnemploymentOther
Total Income per Month
Current Employment Status

Employed Full-TimeEmployed Part-TimeUnemployedStudentRetiredOther
Occupation
Employer
Emergency Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Family Composition

Two Parent FamilyFemale Single ParentMale Single ParentOther Composition
Does your household have a vehicle?

YesNo
Marital Status

SingleMarriedDivorcedWidowedSeparated
Children

YesNo
If yes, please list their names, dates of birth, SSN (if you know) and any other information you'd like us to know.
Please indicate your current family situation.

I have at least 50/50 custody of my childrenI am pregnant or my partner is pregnantI do not have custody of my child/childrenMy children are over the age of 18Due to my living situation, my child/children are not living with me but I do have custody
Are you currently homeless or at risk for becoming homeless?
Reason for homelessness.
Where are you currently staying?

AloneWith FamilyWith FriendsOther
If you selected other - please describe.
How long have you been staying in your current housing situation?

Less than a week7-14 daysOver a monthLess than six monthsMore than a year
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Landlord Information - name, address, phone number
Is your current residence either public or section 8 housing?

YesNoNot housed
Length of stay at this address if behind on rent.
If seeking rental assistance - what is your current rent?
Have you used your Alaska Section 8 housing voucher?

YesNoNot sure
Have you applied for section 8 housing through Alaska Housing and Finance?

YesNoNot sure
Explain details related to your Section 8 voucher (please include last known status).
Referred By

First NameLast Name
Agency or Organization Referral
Reason for Referral
Please briefly describe the event(s) that led to this episode of homelessness.
Are you receiving any of the following supportive services?

Temporary Assistance to Native Families (TANF)Alaska Temporary Assistance Program (ATAP)Women Infants and Children (WIC)Food StampsTlingit and Haida (T&H)MedicaidDenali Medical CareHealth InsuranceWork ProgramTransportation AssistanceClothing AssistanceOther
If yes, please provide details
We understand that the circumstances leading you to seek services may be complex, traumatic, and emotionally charged. If you prefer to discuss the following sections in person, you may leave them blank. Please note that your answers will not affect your eligibility for services. We ask that you answer honestly and to the best of your ability.
Current Medications
Medical Conditions
Mental Health History
Are you currently fleeing an active domestic abuse situation?

YesNo
Have you experienced domestic violence in the past?

YesNo
If you feel comfortable, please explain your domestic abuse situation. Please include date of last encounter.
Household's Monthly Income Source(s)
Payment Basis (weekly, monthly, etc)
Monthly Income Total
Indicate which bills you currently have

RentElectricity (AELP)PhoneInternetInsuranceCredit CardsCar PaymentsChild SupportMisc.Type option 4Other
Monthly Expense Total
Do you receive an annual PFD?

YesNoNot sure
If eligible for FPJ's Homeless Prevention program, are you willing to participate in a self-sufficiency program? This will require weekly contact with a Case Manager and a commitment to work on goals set collaboratively with them.

YesNo
What are your goals for seeking services and what barriers have prevented you from accessing housing?
What outcomes are you hoping to achieve?
Is there anything else you would like us to know?
Client's Name - Head of Household

First NameLast Name
I affirm that the information in this form is true and accurate according to my knowledge.
Signature

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