Families At-Risk Homelessness

Orange County Family Solutions Collaborative

The Family Solutions Collaborative is a coalition of the leading family service nonprofits in Orange County and was formed to streamline the process for homeless families to be connected to the services they need.

Is your family at-risk of homelessness?

Please complete the form below and the information will be directed via email to a Family Service Navigator at your nearest Access Point (the location where a family receives support and referrals to appropriate housing options).
How did you hear about us?*
General Information - Adults
How many adults are in the Household?*
Please select "4" if there are 4 or more adults in the household.
Head of Household Information - Adult #1
Head of Household - Full Name*
Head of Household - Date of Birth*
Month
Day
Year
Head of Household - Last 4 Digits of Social Security Number*
If you do not have an SSN, please enter 0000
Head of Household - Gender*
Head of Household - Race*
Select all that apply
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Multi-Racial
- Refuse to Answer
Please Specify*
Head of Household - Ethnicity*
- Hispanic/Latino
- Non-Hispanic/Non-Latino
Head of Household - Veteran Status*
- Yes
- No
Does the Head of Household have a disabling condition?*
- Yes
- No
Head of Household - Primary language*
Is the Head of Household Employed?*
- Yes
- No
Head of Household - Job Title*
Head of Household - City of Employment*
Head of Household - Hours Worked per Week*
Head of Household - Length of Employment*
Is the Head of Household Covered by Health Insurance?*
- Yes
- No
Adult #2
Adult #2 - Full Name*
Adult #2 - Relationship to Head of Household*
Adult #2 - Date of Birth*
Month
Day
Year
Adult #2 - Last 4 Digits of Social Security Number*
If this adult does not have an SSN, please enter 0000
Adult #2 - Gender*
Adult #2 - Race*
Select all that apply
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Multi-Racial
- Refuse to Answer
Please Specify*
Adult #2 - Ethnicity*
- Hispanic/Latino
- Non-Hispanic/Non-Latino
Adult #2 - Veteran Status*
- Yes
- No
Does Adult #2 Have a Disabling Condition?*
- Yes
- No
Adult #2 - Primary Language*
Is Adult #2 Employed?*
- Yes
- No
Adult #2 - Job Title*
Adult #2 - City of Employment*
Adult #2 - Hours Worked per Week*
Adult #2 - Length of Employment*
Is Adult #2 Covered by Health Insurance?*
- Yes
- No
Adult #3
Adult #3 - Full Name*
Adult #3 - Relationship to Head of Household*
Adult #3 - Date of Birth*
Month
Day
Year
Adult #3 - Last Four Digits of Social Security Number*
If this adult does not have an SSN, please enter 0000
Adult #3 - Gender*
Adult #3 - Race*
Select all that apply
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Multi-Racial
- Refuse to Answer
Please Specify*
Adult #3 - Ethnicity*
- Hispanic/Latino
- Non-Hispanic/Non-Latino
Adult #3 - Veteran Status*
- Yes
- No
Does Adult #3 Have a Disabling Condition?*
- Yes
- No
Adult #3 - Primary Language*
Is Adult #3 Employed?*
- Yes
- No
Adult #3 - Job Title*
Adult #3 - City of Employment*
Adult #3 - Hours Worked per Week*
Adult #3 - Length of Employment*
Is Adult #3 Covered by Health Insurance?*
- Yes
- No
Additional Adults
Other Adults - General Information*
FOR ALL ADDITIONAL ADULTS IN YOUR HOUSEHOLD: Please list their Full Name, Relation to Head of Household, Date of Birth, Last 4 of Social Security Number, Gender, Race, Ethnicity, Veteran Status, Disability Status, Primary Language, Employment Status and if applicable, Job Title, City of Employment, Hours Worked per Week, Length of Employment and if the adult is covered by health insurance.
Contact Information
Primary Phone Number*
Alternate Phone Number
Email
Enter Email Confirm Email
When is the Best Time to Reach You?*
Current Street Address*
Street Address Address Line 2
City*
Zip Code*
ZIP Code
Child Information
How many children are in the household?*
Please select "6" if there are 6 or more children in the household.
Child #1
Child #1 - Full Name*
Child #1 - Relation to Head of Household*
Child #1 - Date of Birth*
Month
Day
Year
Child #1 - Last Four Digits of Social Security Number*
If this child does not have an SSN, please enter 0000
Child #1 - Gender*
Child #1 - Race*
Select all that apply
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Multi-Racial
- Refuse to Answer
Please Specify*
Child #1 - Ethnicity*
- Hispanic/Latino
- Non-Hispanic/Non-Latino
Does Child #1 Have a Disabling Condition?*
- Yes
- No
Is Child #1 Covered by Health Insurance?*
- Yes
- No
Child #1 - School District or Childcare Program*
Child #1 - What Percentage of Custody Do You Have of This Child?*
Child #2
Child #2 - Full Name*
Child #2 - Relation to Head of Household*
Child #2 - Date of Birth*
Month
Day
Year
Child #2 - Last Four Digits of Social Security Number*
If this child does not have an SSN, please enter 0000
Child #2 - Gender*
Child #2 - Race*
Select all that apply
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Multi-Racial
- Refuse to Answer
Please Specify*
Child #2 - Ethnicity*
- Hispanic/Latino
- Non-Hispanic/Non-Latino
Does Child #2 Have a Disabling Condition?*
- Yes
- No
Is Child #2 Covered by Health Insurance?*
- Yes
- No
Child #2 - School District or Childcare Program*
Child #2 - What Percentage of Custody Do You Have of This Child?*
Child #3
Child #3 - Full Name*
Child #3 - Relation to Head of Household*
Child #3 - Date of Birth*
Month
Day
Year
Child #3 - Last Four Digits of Social Security Number*
If this child does not have an SSN, please enter 0000
Child #3 - Gender*
Child #3 - Race*
Select all that apply
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Multi-Racial
- Refuse to Answer
Please Specify*
Child #3 - Ethnicity*
- Hispanic/Latino
- Non-Hispanic/Non-Latino
Does Child #3 Have a Disabling Condition?*
- Yes
- No
Is Child #3 Covered by Health Insurance?*
- Yes
- No
Child #3 - School District or Childcare Program*
Child #3 - What Percentage of Custody Do You Have of This Child?*
Child #4
Child #4 - Full Name*
Child #4 - Relation to Head of Household*
Child #4 - Date of Birth*
Month
Day
Year
Child #4 - Last Four Digits of Social Security Number*
If this child does not have an SSN, please enter 0000
Child #4 - Gender*
Child #4 - Race*
Select all that apply
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Multi-Racial
- Refuse to Answer
Please Specify*
Child #4 - Ethnicity*
- Hispanic/Latino
- Non-Hispanic/Non-Latino
Does Child #4 Have a Disabling Condition?*
- Yes
- No
Is Child #4 Covered by Health Insurance?*
- Yes
- No
Child #4 - School District or Childcare Program*
Child #4 - What Percentage of Custody Do You Have of This Child?*
Child #5
Child #5 - Full Name*
Child #5 - Relation to Head of Household*
Child #5 - Date of Birth*
Month
Day
Year
Child #5 - Last Four Digits of Social Security Number*
If this child does not have an SSN, please enter 0000
Child #5 - Gender*
Child #5 - Race*
Select all that apply
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Multi-Racial
- Refuse to Answer
Please Specify*
Child #5 - Ethnicity*
- Hispanic/Latino
- Non-Hispanic/Non-Latino
Does Child #5 Have a Disabling Condition?*
- Yes
- No
Is Child #5 Covered by Health Insurance?*
- Yes
- No
Child #5 - School District or Childcare Program*
Child #5 - What Percentage of Custody Do You Have of This Child?*
Additional Children
Additional Children - Information*
FOR ALL REMAINING CHILDREN IN YOUR HOUSEHOLD: Please list the Full Name, Relation to Head of Household, Date of Birth, Last 4 Digits of SSN, Gender, Race, Ethnicity, Disability Status, Health Insurance Coverage, School District or Childcare Program, What Percentage of Custody You Have of the Child.
Current Living Situation
Type of residence*
- Rental
- Rental, with a voucher (Section 8 or similar)
- Rental, in affordable housing
- Rental with family/friends/roommates
- Staying with family temporarily
- Staying with friends temporarily
How long has this been your living situation?*
What resources do you need to stay there longer?*
What is the reason you cannot stay in your current housing situation?*
Do you have a lease?*
- Yes
- No
Are you listed on the lease?*
- Yes
- No
How much do you pay monthly towards your rent? ($)*
Is there any adult in the household who resides with you, but for whatever reason is not listed on the lease?*
- Yes
- No
Is there any adult listed on the lease (as a cosigner or resident) who does not currently reside with you?*
- Yes
- No
Have you received an eviction notice, or 3 day pay or quit?*
- Yes
- No
Eviction, Date Received:
Month
Day
Year
3 Day Pay or Quit, Date Received:
Month
Day
Year
What is your current balance of past due rent? ($)*
Income
Please include the amounts of all income you receive.
Earned Income from Employment ($):
Unemployment Insurance ($):
Child Support ($):
Alimony or Spousal Support ($):
Disability Insurance SSI or SSDI ($):
CalWORKS/Cash Aid ($):
Cal Fresh ($):
Other Income, Please Specify ($):
Final Questions
How long have you been in Orange County?*
What kind of services are you requesting?*
You may select more than one
- Rental Assistance (Prevention)
- Utility Assistance
- Life Skills
- Workforce/Job Training
- Counseling
- Medical
- Case Management
- Basic Needs
- Other (Please Specify)
Services Requested - Other*
If you require other services, please describe them here.
Have you or someone in your family ever been legally evicted?*
- Yes
- No
Do you require immediate medical attention?*
- Yes
- No
Do you feel safe where you are staying?*
- Yes
- No
Is anyone in the family currently pregnant?*
- Yes
- No
Do you have access to food?*
- Yes
- No
Do you have a vehicle?*
- Yes
- No
Where will you stay tonight?*
Has your household been impacted by COVID-19?*
- Yes
- No
Do you have any pets?*
- Yes
- No
How many?*
How many of these pets are service animals?*
How many of these pets are emotional support animals?*
To best assist you, your information may need to be shared with other agencies within the Family Solutions Collaborative. Do you give us permission to share your information to assist in securing resources?*
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.

Orange County Family Solutions Collaborative

Is your family at-risk of homelessness?

General Information - Adults

Head of Household Information - Adult #1

Adult #2

Adult #3

Additional Adults

Contact Information

Child Information

Child #1

Child #2

Child #3

Child #4

Child #5

Additional Children

Current Living Situation

Income

Final Questions