Family Promise of Monmouth County

Each year, Family Promise of Monmouth County provides food, clothing, comprehensive case management, life skills training,  meals and shelter for homeless children and families seeking emergency assistance. We have an Emergency Shelter program for Monmouth County residents only. 

We also provide prevention and stabilization support for families facing eviction or foreclosure (based upon available funding).

Completing this screening does not guarantee placement however, it is required to be considered for our program.

*This on-line application will take approximately 10 minutes to complete.* 
 
If you are unable to complete the form online, please contact us for further assistance at 732-495-1050, or email at Lenore@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. Lead Applicant Contact

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* 4. What is your gender?

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* 5. Your Date of Birth

Date

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* 6. Do you have the following items for yourself  (Please check all that apply)

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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. What is your current marital status?

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* 10. Including yourself, how many people are in your household?

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* 11. What services are you seeking from Family Promise? Check all that apply.

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* 12. Where do you currently live?

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* 13. Are you currently facing eviction or foreclosure?

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* 14. Have you received legal notice to appear in landlord/tenant court?

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* 15. Have you contacted Legal Aide?

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* 16. What is the dollar amount of your past due rent/mortgage?

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* 17. If you are seeking emergency shelter, please give us the reason for homelessness?

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* 18. If you are seeking assistance other than emergency shelter, briefly describe the reason you need assistance.

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* 19. Are you employed?

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

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* 21. What is your approximate monthly household income? 

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* 22. Please provide the following information for any other adult household member seeking placement with you. (If there are no other adults, please type "none")

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* 23. Do you have the following items for this adult  (Please check all that apply)

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* 24. Please list your children's names and Date of Birth 

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* 25. Are you the parent or legal guardian of these children?

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* 26. Do you have birth certificates for these children?

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

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

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* 29. Do you have your own vehicle?

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* 30. Do you have health insurance?

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

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

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* 33. Do you or any adult member of your household have a criminal history? Check all that apply. If yes, please indicate which household member.

Our emergency shelter 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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* 34. Are you or a member of your household currently receiving mental health services? If, yes please indicate which household member.

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* 35. 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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* 36. Are you or a member of your household a victim of domestic violence?

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

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* 38. Have you ever received emergency shelter placement from Family Promise of Monmouth or a different Family Promise Affiliate?

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

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* 40. Please upload photo ID for all adults in your household

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

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* 41. Please upload proof of income for all adults in your household

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

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