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*

MM

DD

YYYY

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

MM

DD

YYYY

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

MM

DD

YYYY

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?

MM

DD

YYYY

If you have a 3 Day Pay or Quit, when did you receive it?

MM

DD

YYYY

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

MM

DD

YYYY

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?

MM

DD

YYYY

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

MM

DD

YYYY

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

MM

DD

YYYY

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

MM

DD

YYYY

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

MM

DD

YYYY

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

MM

DD

YYYY

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

Name

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