Homeless Family Services Applicant Information Form (Screening) The Homeless Family Services Program offers case management to homeless families working to gain and maintain self-suffiency. In order to be eligible for our services under the Community Based Case Management program, the family must have dependents (either dependent children age 18 and below or elderly in dependent care). Please fill out the following information so that we are able to begin determining eligibility. Applicant Name:*Spouse/Partner Name (if applicable):Number of dependents living with you:Phone Number:Email:* I am currently spending my nights:* On the street/campground or in my car Emergency Cold Weather Plan In a hotel/motel With a friend or family member Other If other, please explain:How long have you been homeless?Are you currently employed?*YesNoIf yes, where and for how long?Hourly Wage and approximately how many hours per week:Is your spouse/partner currently employed?*YesNoNot ApplicableIf yes your spouse/partner is currently employed, where and for how long?Do you receive any of the following?* ATAP/TANF SSI/SSDI Food Stamps Unemployment Child Support Native Corporation Dividend Other None of the above If other, please explain:What is your total estimated monthly income?Where did you hear about our program?Is a referring agency filling out this form?*YesNoFiling Agency Completing Form:*Name:*Person Completing FormPhone Number:*Email:* Δ