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*

MM

DD

YYYY

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*

MM

DD

YYYY

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*

MM

DD

YYYY

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*

MM

DD

YYYY

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*

MM

DD

YYYY

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*

MM

DD

YYYY

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*

MM

DD

YYYY

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*

MM

DD

YYYY

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*

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:

MM

DD

YYYY

3 Day Pay or Quit, Date Received:

MM

DD

YYYY

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

Name

This field is for validation purposes and should be left unchanged.