Family Promise of Monmouth County 2019

Each year, Family Promise of Monmouth County provides food, clothing, comprehensive case management, life skills training,  12,597 meals and 5,110 bed-nights for homeless children and families seeking emergency assistance. This is a 90-day Emergency Shelter program for Monmouth County residents only. 

In order to streamline the referral process and minimize our waiting list, we have developed an online Centralized Intake Screening (CIS) process. Completing this screening does not guarantee placement however, it is strongly encouraged.

*This on-line application will take approximately 10 minutes to complete.* 
 
Once our CIS receives the referral, our Family Case Manager, Robin Popoff will contact the applicant to schedule an in-person interview, provide a tour of our Day Center and complete the intake process.

Applicants will have the opportunity to upload important documents on this platform electronically. If they or the referring agency are unable to do so, they will be required to bring:

-Birth certificates
-Social security cards
-Insurance cards
-Photo ID (for all adult household members)
-Immunization records (for all minor household members)
-Custody documentation (where applicable)
-Court Order/other legal documents (where applicable)

*We can assist in obtaining lost/stolen birth certificates, social security cards and photo ID.

If you are unable to complete the form online, please contact us for further assistance at 732-495-1050 or email robin@familypromisemc.org

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* 1. Today's Date

Date 

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* 2. Are you a Social Service Referral Agency? If yes, which agency?

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* 3. Applicant Contact

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* 4. What is your social security number?

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* 5. What is your gender?

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* 6. Your Date of Birth

Month/Date/Year

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* 7. What is your racial or ethnic identity? (Select all that apply.)

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* 8. Are you a Veteran?

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* 9. Where do you currently live?

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* 10. How long have you lived there?

Less than 3 months 6 months 1 year or more
i We adjusted the number you entered based on the slider’s scale.

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* 11. What is your source(s) of income? Check all that apply.

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* 13. Are you the parent or legal guardian of the children listed in the screening?

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* 14. Child's Date of Birth

Date 

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* 15. Child's Name and Sex (Male or Female)

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* 16. Child's Date of Birth

Date 

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* 17. Child's Name and Sex (Male or Female)

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* 18. Child's Date of Birth

Date 

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* 19. Are your school-aged children currently enrolled in school?

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* 20. Are you currently enrolled in school or vocational training?

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* 21. What is your approximate monthly household income? 

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* 22. Do you have your own vehicle?

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* 23. Reason for homelessness?

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* 24. What is your current marital status?

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* 25. Do your dependent children currently have health insurance?

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* 26. Does your family have an active DCP&P Case? If yes, what is your Worker's Name/telephone number?

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* 27. Do you or any adult member of your household have a criminal history? Check all that apply. 

*This is a low barrier program. That means having a criminal history does not prevent admission into the program however, failure to answer fully will result in immediate discharge from the Emergency Shelter Program.

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* 28. Are you or a member of your household currently receiving mental health services? If, yes please indicate which household member.

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* 29. Are you or a member of your household currently receiving treatment for alcohol or substance abuse. If, yes  please indicate which household member.

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* 30. Do you have pets? *Note: FPMC Emergency Shelter Program does not allow pets. However, we have partnerships with other agencies that may be able to assist in animal shelter placement.

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* 31. Please upload proof of income.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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* 32. Please upload your government issued photo identification.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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* 33. Have you ever received emergency shelter placement from Family Promise of Monmouth or a different Family Promise Affiliate?

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* 34. How did you hear about Family Promise of Monmouth County?

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* 35. Is there any other critical information that you would like to share?

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* 36. Please provide a telephone number where you can be reached.

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