Shelter Intake Form | Interfaith Family Shelter

Fill out this form, and our staff will get back to you when a shelter unit becomes available:

Thank you for your interest in our program. Please fill out this form and our staff will get back to you soon.

Your Name(Required)

First Middle Last

Your Phone(Required)

Include area code. This is the number we will use to contact you, so please provide a current working phone number.

Your Email(Required)

Relationship to Client(Required)

Self

Family member

Other

Current Address or Location

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Location (County)(Required)

Total Number of Family Members needing assistance(Required)

Total Number of Adults(Required)

How many adults will need assistance through our shelter programs?

Total Number of Children(Required)

How many children will need assistance through our shelter programs? (Includes pregnant and pre-natal children)

Do the following apply to anyone in your household? (check all that apply)(Required)

Single father

Pregnant / Recently gave birth

Disability / Significant medical concern

None of the above

Current Monthly Household Income(Required)

Reason for Shelter / Assistance Request(Required)