If you are staying with a friends/family or currently paying for a hotel on your own and think that we can aid you in extending your stay there by helping with paying a bill or giving aid through transportation, food assistance, mediation, etc., fill out this form. Our goal is to keep people from entering the shelter system by helping them stay connected to any support that they have.

***PLEASE NOTE: WE CANNOT PAY FOR ADDITIONAL HOTEL NIGHTS***

To receive aid from our organization, you must meet one of the following definitions of “family” Please select which applies to you:

I have at least one child under 18 in my physical custody at least 50% of the timeI am pregnant (or my partner is pregnant) in the third trimesterI have an adult child over 18 with disabilities, who relies on me for daily livingI have kids who have been removed from the home but have a reunification plan in placeI have a child that is 18 years old or older and still in high school

First Name

Last Name

Phone

Birthdate

Gender Identity

Other Gender Identity

Which County do you Reside in?

What is your family demographic?

Other Demographic

Where did u stay last night ?

Checkout Date

How much longer are you able to pay for your room?

number of days

How long can you stay at your friend/ family's house?

Is this your first time experiencing homelessness?

How many episodes of homelessness have you had?

What is the living situation like at the place you're staying at with your friend or family member?

(i.e. Do you have your own room? How is your relationship with that person?)

Are you having or do you predict any difficulties in this living situation with this friend or family member?

Would it be helpful if a Family Advocate were to talk to the person/people you’re staying with?

Sometimes we provide financial assistance, gift cards, or help with bills to make it easier for folks to continue staying where they are at, rather than coming into shelter. Do you think any of the following services would be helpful in extending your stay?

List any specific ways that we might be able to help you extend your stay in that situation, even for just a couple more weeks.

Anything else you would like to add about your housing situation that would help us?

Referred by

Referral Notes

By filling out this form, you are being added to our client contact list so we can contact you in the future. You can contact us to be removed at any time by e-mailing us at hello@fpgd.org.

Hidden Fields

Client Intake Record Type ID

Account Record Type ID

Account Source

Client

Service Client Seeks

Rapid Intake

Client Intake

Assisted Program

Contact Information