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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.

Are you a family who is currently experiencing homelessness or at risk for becoming homeless?

Please complete the form below (Client Profile Form) and the information will be directed via e-mail to a Family Service Navigator at your nearest Access Point (location where a family receives support and referrals to appropriate housing options).
How did you hear about us?*
Requested Services*
You may select more than one
- Basic Needs
- Housing
- Workforce/Job Training
- Case Management
- Life Skills
- Counseling
- Medical
- Other (Please Specify)
Services Requested - Other
If you require other services, please describe them here.
Has your family been impacted by COVID-19? (Job loss, unable to pay rent, utilities, medical concerns, etc).*
- Yes
- No
How many adults in the household?*
Please select "4" if there are 4 or more adults in the household.
Head of Household
Head of Household - Full Name*
Head of Household - Date of Birth*
Month
Day
Year
Head of Household - Gender*
Head of Household - Last 4 Digits of Social Security Number*
Head of Household - Disability Status*
- Yes
- No
Head of Household - Veteran Status*
- Yes
- No
Head of Household - Race*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- White
- Don't Know
- Refuse to Answer
Head of Household - Ethnicity*
- Hispanic
- Non-Hispanic
Head of Household - Employed?*
- Yes
- No
Head of Household - Length of Employment
Head of Household - Position Title/Location
Head of Household - Monthly Income ($)
Head of Household - Part-Time or Full-Time Employment?
- Part-Time
- Full-Time
Adult #2
Adult #2 Full Name
Adult #2 Date of Birth
Month
Day
Year
Adult #2 Gender
Adult #2 Relationship to Head of Household
Adult #2 Last 4 Digits of Social Security Number
Adult #2 Disability Status
- Yes
- No
Adult #2 Veteran Status
- Yes
- No
Adult #2 Race
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- White
- Don't Know
- Refuse to Answer
Adult #2 Ethnicity
- Hispanic
- Non-Hispanic
Adult #2 - Employed?
- Yes
- No
Adult #2 - Length of Employment
Adult #2 - Position Title/Location
Adult #2 - Monthly Income ($)
Adult #2 - Part-Time or Full-Time Employment?
- Part-Time
- Full-Time
Adult #3
Adult #3 Full Name
Adult #3 Date of Birth
Month
Day
Year
Adult #3 Gender
Adult #3 Relationship to Head of Household
Adult #3 Last Four Digits of Social Security Number
Adult #3 Disability Status
- Yes
- No
Adult #3 Veteran Status
- Yes
- No
Adult #3 Race
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- White
- Don't Know
- Refuse to Answer
Adult #3 Ethnicity
- Hispanic
- Non-Hispanic
Adult #3 - Employed?
- Yes
- No
Adult #3 - Length of Employment
Adult #3 - Position Title/Location
Adult #3 - Monthly Income ($)
Adult #3 - Part-Time or Full-Time Employment?
- Part-Time
- Full-Time
Other Adults
Other Adults - General Information
Please list the Date of Birth, Gender, Relation to Head of Household, Last 4 of Social Security Number, Disability Status, Veteran Status, Race, Ethnicity, Employment Status (Yes or No), Length of Employment, Position Title/Location, Monthly Income, and If Employment is Part-Time or Full-Time for all remaining adults.
General Information
Primary Phone Number
Alternate Phone Number
Email
Enter Email Confirm Email
Last Permanent Address*
Street Address City State ZIP Code
Primary Language*
Are you currently staying or living in Orange County, CA?*
- Yes
- No
How long have you been a resident of Orange County?
What city are you currently a resident of?*
What is your Santa Ana zip code?*
Do you require immediate medical attention?*
- Yes
- No
Is your current environment safe?*
- Yes
- No
Is anyone in the family currently pregnant?*
- Yes
- No
How far along?
Do you have access to food?*
- Yes
- No
What is your current living situation?*
- Rental
- Living With Family/Friends
Current Monthly Rent ($):
If you have an eviction notice, when did you receive it?
Month
Day
Year
If you have a 3 Day Pay or Quit, when did you receive it?
Month
Day
Year
What resources do you need to stay there longer?
What is the reason you cannot stay in your current housing situation?
How long can you stay there?*
- 1-7 days
- 8-14 days
- 15+ days
Where did you sleep last night?*
Which shelter?
Shelter Exit Date
Month
Day
Year
Motel Name
Who is currently paying for your motel stay?
- I Am/We Are (Self)
- Social Services
- An Agency
How long?
What caused your current situation?*
How much time have you spent in your current situation?*
Where will you stay tonight?*
Do you currently have a voucher or subsidy to help you pay rent reach month?*
Either a current or new voucher/subsidy.
- Yes
- No
Please specify:
When does your voucher expire?
Month
Day
Year
How many children in the household?*
Please select "6" if there are 6 or more children in the household.
Child #1
Child #1 - Full Name
Child #1 - Date of Birth
Month
Day
Year
Child #1 - Gender
Child #1 Disability Status
- Yes
- No
Child #1 - School District or Childcare Program
Child #1 - Do you have full custody of this child?
- Yes
- No
Child #1 - What % custody do you have of this child?
Child #2
Child #2 - Full Name
Child #2 - Date of Birth
Month
Day
Year
Child #2 - Gender
Child #2 Disability Status
- Yes
- No
Child #2 - School District or Childcare Program
Child #2 - Do you have full custody of this child?
- Yes
- No
Child #2 - What % custody do you have of this child?
Child #3
Child #3 - Full Name
Child #3 - Date of Birth
Month
Day
Year
Child #3 - Gender
Child #3 Disability Status
- Yes
- No
Child #3 - School District or Childcare Program
Child #3 - Do you have full custody of this child?
- Yes
- No
Child #3 - What % custody do you have of this child?
Child #4
Child #4 - Full Name
Child #4 - Date of Birth
Month
Day
Year
Child #4 - Gender
Child #4 Disability Status
- Yes
- No
Child #4 - School District or Childcare Program
Child #4 - Do you have full custody of this child?
- Yes
- No
Child #4 - What % custody do you have of this child?
Child #5
Child #5 - Full Name
Child #5 - Date of Birth
Month
Day
Year
Child #5 - Gender
Child #5 Disability Status
- Yes
- No
Child #5 - School District or Childcare Program
Child #5 - Do you have full custody of this child?
- Yes
- No
Child #5 - What % custody do you have of this child?
Additonal Children
Additional Children - Additional Information
Please list the Full Name, Date of Birth, Gender, Disability Status, School District or Childcare Program, If You Have Full Custody of This Child, What Percentage of Custody You Have of the Child if You Do Not Have Full Custody, for all remaining children.
Other Income
CalWORKS/Cash Aid ($):
Child/Spousal Support ($):
Cal Fresh ($):
Disability/SSI ($):
Unemployment ($):
Other Income, Please Specify ($):
Pets
Do you have any pets?*
- Yes
- No
What kind?
How many?
Are they registered as a service animal(s)?
- Yes
- No
Final Questions
Do you have a vehicle?*
- Yes
- No
Are you willing to go to a communal or shared shelter?*
- Yes
- No
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
Phone
This field is for validation purposes and should be left unchanged.

Orange County Family Solutions Collaborative

Are you a family who is currently experiencing homelessness or at risk for becoming homeless?

Head of Household

Adult #2

Adult #3

Other Adults

General Information

Child #1

Child #2

Child #3

Child #4

Child #5

Additonal Children

Other Income

Pets

Final Questions