FPGS Emergency Shelter Question Title * 1. Name OK Question Title * 2. Age OK Question Title * 3. Are you employed? Yes No Disabled OK Question Title * 4. If employed how many hours per week? less than 25 hours per week 25-35 hours 35-40+ hours OK Question Title * 5. Who is your current employer? OK Question Title * 6. If employed, what is the weekly work schedule? 6:30am-3:30pm 8:00am-5:00pm 3:00pm-11:00pm 11:00pm-7:00am Varies OK Question Title * 7. Do you have a partner/spouse? Yes No OK Question Title * 8. Spouse/Partner Name OK Question Title * 9. Age OK Question Title * 10. Is he/she employed? Yes No Disabled OK Question Title * 11. Who is your current employer? OK Question Title * 12. If employed how many hours per a week? less than 25 hours per week 25-35 hours 35-40+ hours OK Question Title * 13. If employed, what is the weekly work schedule? 6:30am-3:30pm 8:00am-5:00pm 3:00pm-11:00pm 11:00pm-7:00am Varies OK Question Title * 14. Please list child(ren) names, ages and school Name Age School School Gender OK Question Title * 15. Please list child(ren) names, ages and school Name Age School School Gender OK Question Title * 16. Please list child(ren) names, ages and school Name Age School School Gender OK Question Title * 17. Please list child(ren) names, ages and school Name Age School School Gender OK Question Title * 18. Please list child(ren) names, ages and school Name Age School School Gender OK Question Title * 19. Do you have any other children in the home not listed? Yes No OK Question Title * 20. How long have you and your family been homeless? Between 1-30 days More than one month less than three months More than three months less than six months More than six months less than a year Over one year OK Question Title * 21. How did you become homeless? Eviction Lack of income (hours decreased, terminated) Health or medical condition Fleeing a domestic or unsafe relationship Loss of income (spouse or partner left the residence) Childcare (inability to maintain employment unstable childcare) Lack of reliable transportation Relocation Other (please specify) OK Question Title * 22. Where are you currently living? On the street? In an automobile? In a location not fit for living? In another homeless shelter or program? With family and/or friends? Pending eviction Other (please specify) OK Question Title * 23. How many times has the family been homeless in the last three years? First episode 2-3 times More than 3 times OK Question Title * 24. Do you have a vehicle? yes no OK Question Title * 25. Have you applied for public housing? yes no OK Question Title * 26. Are you pregnant? yes no OK Question Title * 27. Due Date? OK Question Title * 28. What are your sources of income? (check all that apply) Earned Income (for ADULT household members only) Self-employment/Business Income Pension/Retirement Income Unemployment/Disability Income TANF/Public Assistance Income Alimony/Child Support/Foster Care Income Other OK Question Title * 29. How much do you receive monthly for the source(s) of income selected? OK Question Title * 30. Do you have monthly expenses? (please check all that apply) Car payment Insurance Cell phone Storage Other None OK Question Title * 31. Do you have unpaid balances on past due utility bills? Electric bill (Georgia Power) Water bill (City of Savannah) Gas bill (Scana, Georgia Natural Gas, etc..) None OK Question Title * 32. Do you have any evictions ? yes no OK Question Title * 33. What is your last known address? OK Question Title * 34. How were you referred to Family Promise of Greater Savannah Website or social media United Way 211 Chatham Savannah Authority for the Homeless Savannah Chatham County Public School System Friend or former guest Community agency Other OK Question Title * 35. Contact Number OK Question Title * 36. Do you have any other comments, questions, or concerns? OK Question Title * 37. Alternate contact number or email address OK DONE