Welcome

1
Name* This field is required.
First Name
Last Name
2
Are you a returning client?* This field is required.
YESNO
3
Who referred you?* This field is required.Type N/A if not applicable
4
If you are a returning client, please select the case manager you are currently assigned to:* This field is required.
Lauren F.
Tambi C.
Lex E.
I don't remember
I am a new client
My case manager is not listed
5
Your Phone Number* This field is required.
Area Code
Phone Number
6
Your Email
example@example.com
7
Enter your Date of Birth* This field is required.
Date
Month
Day
Year
8
Address* This field is required.Type "homeless" if you do not have a physical address, in the street address. For the remaining fields, please indicate which city, state, and zip code you are currently residing in.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Are you or someone in your current household a Veteran of the United States Military?* This field is required.
YESNO
10
Are you or someone in your current household disabled, hard-of-hearing, or visually impaired?* This field is required.
YESNO
11
Emergency Contact* This field is required.You are required to list an emergency contact for our records.
First Name
Last Name
12
Emergency Contact's Number* This field is required.You are required to list an emergency contact for our records.
Area Code
Phone Number
13
Emergency Contact's EmailYou are required to list an emergency contact for our records.
example@example.com
14
How is this emergency contact related to you?* This field is required.
15
Are you or someone in your current household pregnant?* This field is required.
YESNO
16
Select your Marital Status* This field is required.
Single
Married
Separated
Divorced
Widowed
17
What is your race/ethnicity?* This field is required.
African American/Black
American Indian or Alaska Native
Asian
Caucasian/White
Native Hawaiian or other Pacific Islander
Hispanic or Latino
Middle Eastern or North African
Multiracial
18
What's your highest level of education?* This field is required.(Select all that are applicable)
K-8th grade (did not complete past 8th grade)
9th-12 grade (did not graduate)
High School Diploma / GED
College Graduate
Some College (did not graduate)
Vocational / Technical /Trade Certificate (i.e., Beauty School, Electrician, HVAC Technician)
Associates Degree
Bachelors Degree
Masters Degree (or higher)
19
How many places have you lived in the past year?* This field is required.Please count and enter the approximate number of places you have lived in during the past 12 months. Do not count short visits or vacations.
Please Select
Please Select
1
2
3
4 or more
20
What is your current housing status?* This field is required.This question helps us understand your family’s housing situation so we can determine eligibility and connect you with the right services. Choose the option that most closely matches your current living arrangement, even if it feels temporary. If more than one seems to fit, select the one that best describes your primary living situation.
Please Select
Please Select
On the street
Emergency Shelter
Transitional Housing
Car
Trailer
Domestic Violence Shelter
Apartment/house you rent
Apartment/house you own
Living with family/friends as a permanent arrangement (this is intended to be long-term and stable)
Living with family/friends temporarily (this is short-term and you are actively looking for your own place)
Staying/living with friend
Motel
Foster care/group home
Permanent Supportive Housing
Place not meant for habitation (e.g.,car/bus/camp site/outside)
Other
21
If you have recently moved into permanent or stable housing, please describe your living situation(s) over the past 12 months prior to this move.* This field is required.Please select all that apply for the last 12 months
On the street
Emergency Shelter
Transitional Housing
Car
Trailer
Domestic Violence Shelter
Apartment/house you rent
Apartment/house you own
Staying/living with family
Staying/living with friend
Motel
Foster care/group home
Permanent Supportive Housing
Place not meant for habitation (e.g.,car/bus/camp site/outside)
Other
22
When was the last time you had a permanent address (lived there longer than a year) and approximately how long did you live there?* This field is required.Give an approximate date for your last permanent address:
23
How long have you been staying in your current living situation?* This field is required.This includes wherever you are currently staying, such as a home, motel, shelter, car, or with someone else.
Please Select
Please Select
A couple of nights
1 week
Less than a month
1-3 months
4-6 months
7-12 months
1-2 years
2-4 years
4 or more years
24
Select your current household type:* This field is required.Select that which is applicable to your household type.
Single mother with children
Single father with child(ren)
Two parents with child(ren)
Pregnant individual (no other children currently in home)
Unaccompanied youth (under 18 not living with parent/guardian)
Extended family member (e.g., grandparent, aunt, cousin) currently caring for relative children in my household.
Caregiver to non-biologically related children (e.g., family friend, godparent, informal placement)
DCF Certified Foster Parent
25
Family/Child Information* This field is required. PLEASE MAKE SURE TO MARK THE CORRECT YEAR OF BIRTH OR IT WILL DEFAULT TO 1990. MAKE SURE ALL SECTIONS ARE COMPLETED OR IT WILL BE REJECTED DO NOT FORGET TO ADD A ROW FOR EACH CHILD
26
Are you or your partner employed?* This field is required.Type N/A if not yet employed
Employed
Unemployed
Disabled
Retired
Self-Employed
27
Who do you work for? Enter your employers name* This field is required.Please include the name of your employer and the employer of your spouse, significant other, or any household member who contributes to shared expenses. If not employed, type N/A.
28
What is your occupation/title?* This field is required.Enter your occupation/title and the occupation/title of your spouse, significant other, or any household member who contributes to shared expenses. If not employed, type N/A. Example: customer service, team member, manager, technician, driver, etc.
29
How long have you worked there?* This field is required.Enter how long you have worked at your job and how long your spouse, significant other, or any household member who contributes to shared expenses has worked at theirs. If not employed, type N/A.
Please Select
Please Select
Looking for employment
Have not started yet - waiting for start date
Less than a month
1-3 months
4-6 months
7-12 months
1 year
2 years
3 years
4 or more years
N/A
30
What is your hourly pay?* This field is required.Enter your hourly pay and the hourly pay of your spouse, significant other, or any household member who contributes to shared expenses. If not employed, type N/A. I.e., Type 10.00 if you make 10 dollars an hour. Type 0.00 if you are not employed at this time.
31
How many hours do you average weekly at your job?* This field is required.Enter the average number of hours you work weekly and the weekly hours of your spouse, significant other, or any household member who contributes to shared expenses. If not employed, type N/A.
32
How often do you get paid?* This field is required.Select how often you are paid (weekly, bi-weekly, semi-monthly, or monthly). Be sure to also provide the pay frequency for your spouse, significant other, or any household member who contributes to shared expenses. If not employed, type N/A.
Weekly
Once every 2 weeks
Once a month
N/A: Self Employed (will require confirmation of income)
N/A: Unemployed
33
Income* This field is required.Enter the approximate dollar amount of your net MONTHLY income. You are required to report ALL sources of income for yourself and any other person who resides in your household who contributes to rent, utilities, food, childcare, or any other shared expenses. This includes (but is not limited to) income from a spouse, significant other, family member, or roommate who helps support your household. If you are currently unemployed or not receiving any income, enter 0.00. Please also enter 0.00 in any fields that do not apply to you (for example: Veteran Benefits, Alimony, etc.). ⚠️ Important: This section must be completed accurately and in full. Failure to disclose all household income or providing unclear information may delay services and/or require an in-person intake appointment for clarification.
Dollar Amount
Employment
Row 0, Column 0
Social Security Income / Disability
Row 1, Column 0
SNAP/Food Stamps
Row 2, Column 0
Unemployment
Row 3, Column 0
Veteran Benefits
Row 4, Column 0
Child Support
Row 5, Column 0
Alimony
Row 6, Column 0
Pension
Row 7, Column 0
Other employment / Side Jobs
Row 8, Column 0
Employment
Social Security Income / Disability
SNAP/Food Stamps
Unemployment
Veteran Benefits
Child Support
Alimony
Pension
Other employment / Side Jobs
Dollar Amount
Row 0, Column 0
Dollar Amount
Row 1, Column 0
Dollar Amount
Row 2, Column 0
Dollar Amount
Row 3, Column 0
Dollar Amount
Row 4, Column 0
Dollar Amount
Row 5, Column 0
Dollar Amount
Row 6, Column 0
Dollar Amount
Row 7, Column 0
Dollar Amount
Row 8, Column 0
1 of 9
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Expenses* This field is required.Please enter the total monthly cost for each category listed below. If you do not pay anything toward a specific category, enter 0.00. Report only the portion of expenses you or your household are responsible for. Be sure to provide the monthly amount (not weekly). ⚠️ Important: This section must be completed accurately and in full. Failure to disclose all household expenses or providing unclear information may delay services and/or require an in-person intake appointment for clarification.
Dollar Amount
Rent/Mortgage
Row 0, Column 0
Utilities
Row 1, Column 0
Car Payment
Row 2, Column 0
Transportation/Gas (including Uber/Lyft)
Row 3, Column 0
Car Insurance
Row 4, Column 0
Food/Groceries (including how much you receive in food stamps)
Row 5, Column 0
Phone
Row 6, Column 0
Clothing/School Supplies
Row 7, Column 0
Household supplies/maintenance
Row 8, Column 0
Monthly Loan/Credit Card Payments
Row 9, Column 0
Other expenses
Row 10, Column 0
Rent/Mortgage
Utilities
Car Payment
Transportation/Gas (including Uber/Lyft)
Car Insurance
Food/Groceries (including how much you receive in food stamps)
Phone
Clothing/School Supplies
Household supplies/maintenance
Monthly Loan/Credit Card Payments
Other expenses
Dollar Amount
Row 0, Column 0
Dollar Amount
Row 1, Column 0
Dollar Amount
Row 2, Column 0
Dollar Amount
Row 3, Column 0
Dollar Amount
Row 4, Column 0
Dollar Amount
Row 5, Column 0
Dollar Amount
Row 6, Column 0
Dollar Amount
Row 7, Column 0
Dollar Amount
Row 8, Column 0
Dollar Amount
Row 9, Column 0
Dollar Amount
Row 10, Column 0
1 of 11
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Why are you in need of assistance through the Homeless Children's Foundation* This field is required.
Insufficient Income
Medical Condition
Natural Disaster/Fire
Eviction or at Risk of Eviction
High Risk Neighborhood
Loss of Public Assistance (i.e., section 8 voucher)
Mismanagement of income
Domestic Violence
Condemnation
Recently released from corrections facility
Recently widowed
Unable to locate employment / housing
Other
36
Have you ever resided at a family homeless shelter?* This field is required.If yes, please explain approximately when (month/year) and how long you resided there. If not, please type N/A.
37
Have you ever been formally evicted?* This field is required.A formal eviction includes all of the following: written notice from your landlord, court filing, court hearing, and a writ of possession issued by the court. If none of these apply to you, please write N/A. If you have been formally evicted, please provide the following details for each occurrence: the number of formal evictions, the county where the eviction took place, and the month and year of each eviction. Example: 1 formal eviction — Indian River County — March 2021
38
Have you or someone in your current family unit ever been convicted of a crime?* This field is required.Why we ask this: This information helps us understand any potential barriers your family may be facing related to employment, housing, or stability. Past convictions can sometimes create challenges when applying for jobs, renting a home, or accessing certain services. By knowing this, we can better connect you with resources, advocate on your behalf when possible, and provide support tailored to your family’s unique needs. All information you provide will remain confidential and is only used to help us serve you more effectively.
YESNO
39
Have you, as a parent, ever had any child welfare involvement with the Department of Children & Families?* This field is required.Why we ask this: This question helps us understand if there are any prior or current child welfare concerns that may impact your family’s situation. Knowing about past or ongoing involvement with DCF allows us to better coordinate support, connect you with resources, and ensure that we are meeting your family’s needs in a way that aligns with any existing case plans or requirements. All information you share will remain confidential and will only be used to provide you with the best possible assistance.
YESNO
40
Have you ever been a victim of domestic violence?* This field is required.Why we ask this: This information is important because it helps us better understand your situation and the challenges you may be facing. Knowing whether you have experienced domestic violence allows us to connect you with appropriate resources, provide additional support if needed, and ensure that your safety and your children’s safety are prioritized. All information you share will be kept confidential and used only to help us serve you more effectively.
YESNO
41
Are you currently receiving any additional assistance from any local or state providers? * This field is required.Examples include: Treasure Coast Homeless Services Council, Healthy Start, Medicaid, SNAP (food stamps), TANF, Indian River County Human Services, Early Learning Coalition, or local housing programs. If yes, please list which provider you are working with and who is receiving the services. For example, if a child is receiving Medicaid, include the child’s name. If this does not apply, please type N/A.
42
Are you currently receiving mental health services for yourself? * This field is required.This includes therapy or counseling, psychiatric care, or taking medication for conditions like anxiety, depression, trauma, or other mental health needs. If yes, please provide the agency/providers name and their contact information. If not applicable, please type N/A.
43
Are any of the children actively receiving mental health services?* This field is required.Mental health services include counseling, psychiatric care, and medication management for conditions like anxiety, depression, PTSD, or bipolar disorder. This also includes therapy or ADHD medication for children (e.g., Adderall, Vyvanse, Ritalin). If yes, please provide the name and contact information of the agency and/or provider, and indicate which child is receiving the services. If not applicable, type N/A.
44
Please identify up to three goals that you would like to accomplish in the next year:* This field is required.Examples of goals may include: finding stable housing, increasing your income, paying off past due bills, enrolling your child in childcare or aftercare, continuing your education, completing job training, improving your health, or building stronger routines and stability for your children.


Huge
Large
Normal
Small
Ok
Ok
45
What do you believe are the barriers/challenges you are currently facing that could prevent or have prevented you from achieving these goals?* This field is required.Do not leave this field blank.
46
Please summarize the type of assistance you are requesting and explain why you are in need of this assistance:* This field is required.Be as specific as possible (for example: help with aftercare, childcare, housing, clothing, utilities, etc.). Note: The information you provide will help determine your eligibility and priority for services. Please be detailed so we can best understand your situation and needs.
47
HCF FAMILY MEDIA CONSENT AND RELEASE FORM
Homeless Children’s Foundation of Indian River County

Throughout the year, photos/videos are taken of the children funded by Homeless Children’s Foundation of Indian River County (HCF) for
newsletters, fundraising, and website updates. The main purpose of these photos/videos is to update donors and potential donors of HCF and keep
our program running financially, so we can support as many children as possible.

Images and videos may be shared for a period that does not expire, unless written request for expiration is given, regarding the welfare of the above-named client(s) and family. I understand that I may revoke this consent of release at any time except to the extent that action has been taken in reliance of such information. I understand that if a photo/video of myself or my children is used, our full names are not released to identify us. I understand the above statements and consent and release of media taken and video about me and any dependents, and authorize information collected to be shared with program providers and partner agencies. I understand that the images and videos will not be made public and will only be used with strict confidentiality. I also understand that I may withdraw my consent at any time in writing with this agency. I understand that I may obtain a copy of my signed consent and release form from this Agency (including forms signed electronically).

By signing this form, you agree to the consent and release of these photos/videos of your dependent children under 18 in household, if any.
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I, First Name * Last Name * , hereby authorize Homeless Children’s Foundation of Indian River County, and any of its employees to use the images or videos of myself or any children within my household in connection with programs and service providers.
49
Do you give consent for HCF to use photos/videos of your child(ren) for the purposes stated above?* This field is required.
Yes, I give consent.
No, I do not give consent
50
Parent/Guardian Signature* This field is required.Please sign below to confirm that you have reviewed and acknowledged your selection regarding media consent in the previous section—whether you chose to give or not give consent. Your signature confirms your understanding and final decision.
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51
HCF FAMILY
CONSENT FOR RELEASE OF INFORMATION

The Homeless Children’s Foundation of Indian River County is a team working together with local partner agencies to provide services to homeless and low-income families in Indian River County. These partner agencies include shelter, housing, food, state, private and non-profit social service agencies, and faith-based organizations.

I understand that this information is for the purpose of assessing needs for housing, utility assistance, food, counseling and/or other services.

The information being shared may consist of the following:

• Identifying and/or historical information regarding my household.
• My household income, non-cash benefits, and health insurance information.

I understand that:

• Information I give concerning physical or mental health problems will not be shared with other partner agencies in any way that identifies me or other members of my household.
• The partner agencies have signed agreements to treat my household’s information in a professional and confidential manner. I have the right to view the client confidentiality policies used by the HCF.
• Staff members of the partner agencies who will see my household’s information have signed agreements to maintain confidentiality regarding my household’s information.
• The partner agencies may share non-identifying information about the people they serve with other parties working to end homelessness.
• I have the right to ask if I may refuse to answer certain questions.
• The sharing of information does not guarantee that services will be provided. Declining to share information does not prohibit the provision of services.
• This authorization will remain in effect for twelve months unless I revoke it in writing.
• If I revoke my authorization, all information about my household entered into the database from that date forward will not be shared with partner agencies.
• A list of the partner agencies within the network may be viewed prior to signing this form.
52
I, First Name * Last Name * , give this partner agency permission to share the following
information regarding my household. I understand that this information is for the purpose of assessing needs for housing, utility assistance, food, counseling and/or other services.
53
Please list the agency you are giving us permission to communicate/partner with on behalf of yourself or your children:* This field is required.Example: Cleveland Clinic, Healthy Start, Children’s Home Society, School District of Indian River County. Type N/A if not applicable.
54
Please list the full name and date of birth for each individual this consent form applies to.* This field is required.This may include yourself and/or your child(ren). If the consent applies to the entire family, please list the full name and date of birth for each family member you are authorizing us to communicate on behalf of.
55
Parent/Guardian Signature* This field is required.Please sign below to confirm that you have read and understand this consent form. Your signature indicates that you give permission for us to communicate with the agency or agencies listed above on behalf of yourself and/or your child(ren). If you do not give consent, your signature still confirms that you reviewed and acknowledged the form.
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HCF FAMILY MEDIA CONSENT AND RELEASE FORM Homeless Children’s Foundation of Indian River County

HCF FAMILYCONSENT FOR RELEASE OF INFORMATION

HCF FAMILY MEDIA CONSENT AND RELEASE FORM
Homeless Children’s Foundation of Indian River County

HCF FAMILY
CONSENT FOR RELEASE OF INFORMATION