Family Self Sufficiency Program

1
This interest form is the first step to ensuring the program is a great fit for you. This form helps us learn about your goals, strengths, and the supports that may be helpful to you. There are no right or wrong answers.

It does not obligate you to participate, nor do any responses affect your housing status.

Approximate completion time ~ 5-10 minutes
2
I have an active voucher with Oak Ridge Housing Authority* This field is required.
Yes
No
3

Thank you for your interest in ORHA's FSS program!

Unfortunately, at this time you do not meet eligibility requirements. If you believe this to be an error or for any additional questions, contact us at 865.482.1006
4
What is your Full Name?* This field is required.
First Name
Last Name
5
Email Address* This field is required.
example@example.com
6
Phone Number* This field is required.
Please enter a valid phone number.
7
Do you prefer we text you?* This field is required.
Yes
No, I prefer a phone call
No, I prefer email
8
What is your current address?* This field is required.
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
Which of the following people are part of your circle of support? (Select all that apply)* This field is required.
Parent(s)or guardian(s)
Child(ren)
Spouseor partner
Grandparent(s)
Sibling(s)
Otherrelatives
Friends
Church Members
Neighbors or community members
Coworkers
Mentor, Coach, or Teacher
I do not currently have support
10
How many people do you have in your life that you can turn to for help, advice, or encouragement when you need it?* This field is required.
None right now
1 person
2-3 people
4-5 people
More than 5 people
11
When something good happens in your life, who do you celebrate with?* This field is required.
12
When opportunities come up for work, education, or training, how often do you need to consider the needs of your family before making a decision?* This field is required.
Never
Rarely
Sometimes
Often
Almost always
13
During the past 12 months, how often have family or caregiving responsibilities made it difficult to work, attend school/training, or complete important tasks?* This field is required.
Never
Rarely
Sometimes
Often
Almost always
14
Which responsibilities have had the biggest impact? (Select all that apply.)* This field is required.
Childcare
Transportation for family members
Caring for an older adult
Supportinga family member with a health condition
Managing household responsibilities
Family emergencies or crises
Other
15
Who are the people that have had the biggest positive influence on your life and what role have they played in helping you get where you are today?* This field is required.
16
Which statement best describes your educational experience?* This field is required.
I have not yet earned a GED or high school diploma
I earned a GED or high school diploma, but school was often challenging for me
I earned a GED or high school diploma and generally felt successful in school
I completed some education or earned a certification beyond high school
I earned a college degree or advanced credential
17
Which statement best describes where you are in your work or career journey right now?* This field is required.
Right now, my focus is on other priorities besides employment
I am exploring what kind of work I would like to do
I am preparing for work through education, training, or skill-building
I am actively looking for employment
I am working and would like to increase my income, skills, or opportunities
I am working and feel satisfied with my current situation
18
Which of the following are things you're dealing with right now that affect your work, school, training, or future plans? (Select all that apply)* This field is required.
Childcare or parenting responsibilities
Caring for a family member
Transportation
Physical health concerns
Stress, anxiety, or emotional well-being
Education, training, or certifications
Access to technology or internet
Criminal or legal history
Financial challenges
Confidence in my skills or abilities
Limited job opportunities in my area
Other
19
Thinking about your ideal work situation, what matters most to you? (Choose up to 3)* This field is required.
Earning enough to meet my family's needs
Flexible hours or schedule
Health insurance or benefits
Retirement benefits
Meaningful or purposeful work
Helping others
Job security
Opportunities to advance
Work-life balance
Positive workplace culture
Working independently
Learning new skills
Predictable schedule
Other
20
If training, money, and other obstacles weren't in the way, what kind of work would you like to do?* This field is required.
21
How important is it for you to make a change in your work, education, or career situation within the next year?* This field is required.
Not important right now
Slightly important
Important
Very important
One of my top priorities
22
If you decided to pursue a new job, promotion, education program, or career goal in the next six months, how ready do you feel to take that next step?* This field is required.
Not ready right now
Thinking about it but not yet planning
Beginning to make plans
Actively taking steps toward a goal
Ready to take action now
23
When you think about work, what would a really good job look like for you?* This field is required.
24
Which of these do you currently use to receive, keep, or manage your money? (Select all that apply)* This field is required.
Checking account at a bank or credit union
Savings account at a bank or credit union
Prepaid debit card
Cash App, Chime, Venmo, PayPal, or another payment app
Cash kept at home or with someone I trust
Check-cashing or money service
A family member, partner, or trusted person helps manage money
Other
I do not currently have a regular way to keep or manage money
25
When money is tight or an unexpected cost comes up, which resources help you get through? (Select all that apply)* This field is required.
Money I had set aside
Adjusting which bills or expenses I paid first
Help from family or friends
Extra work, side jobs, or selling something
A church, community organization, or assistance program
Credit card, overdraft, or payment plan
Cash advance or Chime
Payday loan, title loan, pawn shop, or rent-to-own service
Tax refund or other expected payment
Going without or delaying something I needed
I have not faced this recently
Something else
26
If an unexpected expense of $500 came up, how much of it could you cover without falling behind on rent, utilities, food, transportation, or other important needs?* This field is required.
All of it
Most of it
About half
A small part of it
None of it right now
I am not sure
27
Which money goals would make the biggest difference for you or your family right now? (Choose up to three)* This field is required.
Having enough money to cover monthly bills
Keeping food, utilities, and other basic needs paid
Catching up on past-due bills
Having money set aside for emergencies
Paying down debt
Improving my credit
Having reliable transportation
Paying for childcare or other family needs
Paying for education, training, or work-related costs
Being able to handle car repairs, medical costs, or other unexpected expenses
Moving into different housing
Saving toward a home of my own
Being able to help family when needed
28
What would having more financial breathing room allow you or your family to do?* This field is required.
29
Outside of your close family and friends, who do you regularly talk with or spend time around? (Select all that apply)* This field is required.
People at my job
People at school or job training
People at church
Parents from my child’s school, daycare, sports, or activities
Neighbors or people where I live
People in a recovery or support group
People in a club, class, team, or community group
A mentor, coach, counselor, caseworker, or other trusted helper
People I volunteer or serve with
People I know mostly online
I mostly spend time with family and close friends
I prefer to keep to myself
30
During the past month, how often has your physical or emotional health made it harder to do the things you need or want to do?* This field is required.
Never
Rarely
Sometimes
Often
Almost every day
31
When something difficult comes up, which statement sounds most like you?* This field is required.
I am often unsure what to do next
I usually need help figuring out what to do next
I can usually think of one or two things to try
I know who I can call or where I can go for help
I feel confident handling problems and asking for help when I need it
32
Where are you with a goal that matters to you?* This field is required.
I am still figuring out what I want to work toward
I have something I want to work toward but am not sure where to start
I know at least one step I can take
I have started taking steps toward something that matters to me
I am making progress and feel hopeful about what comes next
33
Thinking about the past year, what are you most proud of?* This field is required.
34
When you have several things that need to be done, what do you usually do first?* This field is required.
Start with the most urgent thing
Make a list or plan
Ask someone to help me decide
Start with the easiest thing
Handle things as they come up
Sometimes feel stuck or unsure where to begin
It depends on what is happening that day
35
During the past month, what happened when plans changed or something unexpected came up?* This field is required.
I changed my plans and got everything done
I handled the most important things first
I asked for help or made a new plan
I got some things done, but not everything
I had a hard time getting back on track
Nothing unexpected came up this month
36
Which of these have made it harder to complete something important during the past month? (Select all that apply)* This field is required.
Not having enough time
Too many things needing attention at once
Transportation problems
Childcare or family needs
Changes in my work schedule
Stress, worry, or trouble concentrating
Not having the information or paperwork I needed
Not knowing where to begin
Waiting on another person or organization
Nothing made it harder
37
Tell me about a typical day. What does it look like and what are all the things you do to keep life moving for yourself or the people who count on you?* This field is required.
38
Thank you for taking the time to complete this form! We will be in touch within 10 business days.

~~~~~~~~~~~~~~~~~

I’m excited to get to know you and learn what matters most to you. I believe you are the expert on your own life. You know what you have been through, what you are carrying, and where you hope to go.

This work is personal to me. I have been a single mom putting five dollars of gas in the car at a time, a caregiver, and someone learning how to rebuild after hard seasons. Those experiences have shaped the way I support people. With me, you'll get honesty, encouragement, and no judgment. My role is not to tell you what your life should look like, but to listen, help you build meaningful goals, and connect you with the tools and support you need so you aren't carrying the burden alone.

~Melinda Holder
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