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Contact Us

Family Promise of Sacramento

Housing Stability Program

Intake Form

Are you familiar with our program?


To be eligible you must:

  1. Be a family - with at least one adult and at least one minor child.

  2. Be homeless, or about to become homeless.

  3. Be drug free. All adults will be drug tested. Any current users (when entering and participating in our program) of recreational drugs, including marijuana, will not be accepted.


Please read about our program, our housing for participants, and our intake process before completing this intake form.

Sex

We gather this information only for statistical use. It will not be used in selecting families.

If another adult (spouse, partner, ...) will be entering the program with you, please add their information.

Partner's sex

We gather this information only for statistical use. It will not be used in selecting families.

Tell us about your children:

How many minor children will be with you in our program?

List your children's names and ages. Include their last names if different from your own. Birth dates are not necessary.

Tell us about your work:

Working
Yes
No

Are you currently working?

partner working
Yes
No

Is your partner currently working?

If no, when did you last work?

If no, when did your partner last work?

If yes, how long have you been at your current job?

If yes, how long has your partner been at his/her current job?

If yes, where does your partner work, and what job does he/she do there?

If yes, where do you work, and what job do you do there?

How many hours per week do you work?

How many hours per week does your partner work?

What is your hourly wage? If you get paid $16.40 per hour, enter 16.40 .

What is your partner's hourly wage? If he/she gets paid $16.40 per hour, enter 16.40 .

Tell us about your income.

How much do you receive per month from:

(Whole dollars only. If no income, enter 0.)

Job

Partner's job

CalWORKS/cash aid

Partner's CalWORKS/cash aid

CalFresh/food stamps

Partner's CalFresh/food stamps

SSI

Partner's SSI

Monthly income from other sources

Monthly income from partner's other sources

If you listed income from other sources, above, tell us what these other sources are (child support? unemployment from previous employer? ...)

If you listed income from other sources for your partner, above, tell us what these other sources are (child support? unemployment from previous employer? ...)

Tell us about some of your challenges:

Drug use
Yes
No

Do you have a history of drug use or alcohol abuse? (Including marijuana)

Partner drug use
Yes
No

Does your partner have a history of drug use or alcohol abuse? (Including marijuana)

If yes, 1) what is/was the drug, 2) how long have you been sober, and 3) did you participate in a drug/alcohol recovery program. If so, which program?

If yes, 1) what is/was the drug, 2) how long has your partner been sober, and 3) did he/she participate in a drug/alcohol recovery program. If so, which program?

Mental health

Do you have any ongoing or history of mental health conditions?

Partner mental health

Does your partner have any ongoing or history of mental health conditions?

If yes, what have you been diagnosed with? Are you taking any medications to treat it?

If yes, what has your partner been diagnosed with? Is he/she taking any medications to treat it?

Domestic violence

Do you have any history of domestic violence, either as a victim or perpetrator?

Partner domestic violence

Does your partner have any history of domestic violence, either as a victim or perpetrator?

If yes, 1) were you the victim or perpetrator and 2) how long ago?

If yes, 1) was your partner the victim or perpetrator and 2) how long ago?

Arrests

Have you ever been arrested?

Partner arrests

Has your partner ever been arrested?

If yes, 1) when and 2) what for?

If yes, 1) when and 2) what for?

Tell us about your housing history:

How long have your been homeless? What made you homeless?


Times homeless

How many times have you been homeless in the past?

Last night

How many formal evictions are on your record? Enter 0 if none.

When was the last one? Why were you evicted?

Tell us about your vehicles:

Vehicle

Select all that apply.

Is there anything else we should know?

Tell us anything else we should know, or clarify any of your answers.


Inquiries

For any inquiries, questions or recommendations, please email marsha@sacfamilypromise.org or call (916) 443-3107

Sacramento Office

P.O. Box 1378

Sacramento, CA 95812

 

marsha@sacfamilypromise.org

Tel: (916) 443-3107

Fax: (916) 443-3106

​

Current in-office hours: Mon-Thurs, 9am-2pm

(Phone messages left after hours will be answered on the next  in-office day.)

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