New Service Request

Personal Information

[{viewVars.validations.members}]

Please fill all the required fields before proceeding further

Previous Client?

First Name

[{viewVars.validations.firstName}]

Middle name

[{viewVars.validations.middleName}]

Last Name

[{viewVars.validations.lastName}]

DOB

[{viewVars.validations.dob}]

SSN (Full or Last 4)

[{viewVars.validations.ssn}]

If you are under 18 and the only person in this household, please check this box

Phone

[{viewVars.validations.phone}]

[{viewVars.validations.email}]

Citizenship Status

Legal History: (Check all that apply)

[{pr}]

Legal History Details

Address Line 1

[{viewVars.validations.address}]

Address Line 2

[{viewVars.validations.address2}]

State

ZIP Code

[{viewVars.validations.zip}]

County

City

Tell us how we can help you

Are you currently homeless?

Gender

[{viewVars.validations.ethnicity}]

Ethnicity

[{viewVars.validations.ethnicity}]

Race

[{$item}]

[{k}]

Language

[{$item}]

[{k}]

Health Insurance

[{$item}]

[{k}]

Disability?

Marital Status

[{viewVars.validations.marital}]

Highest Level Education

[{viewVars.validations.education}]

Employment Status

[{viewVars.validations.employment}]

Veteran Status

[{viewVars.validations.veteran}]

Are you currently experiencing a financial crisis? If so, please describe the situation.

Have you sought assistance from other sources/organizations? What was the outcome?

Can you provide documentation of the financial crisis?

[{viewVars.validations.documentation}]

View Delete

What support or service would have been most helpful in avoiding this situation?

Where have you slept in the last thirty (30) days?

When was the last time you lived at a permanent address?

What contributed to your ability to maintain this permanent residence? Please explain.

Identified barriers to obtaining or maintaining stable housing: (Check all that apply)

[{pr}]

Specify

Are you receiving a housing subsidy?

If so, what type and details (amount, duration, etc.)

What is your housing goal for the next 18 months?

[{viewVars.validations.housingGoal}]

Unemployed adults in the home, please identify employment barriers. (Check all that apply)

[{pr}]

Specify

Have you have experienced any physical health, mental health, and/or substance use issues, what impact has it had on your daily functioning and ability to maintain stable housing?

[{viewVars.validations.healthIssues}]

On a scale from 1-10, How motivated are you to change your current circumstances?

Have you taken any steps/actions to change your current circumstance?

[{viewVars.validations.changeSteps}]

If so, please elaborate on steps made, success/challenges, and impact:

Disclaimer: These questions will not affect your eligibility for assistance from RBF

Do you identify with any of the following religions? (Check all that apply)

[{pr}]

Specify

How do you engage with your religious/spiritual beliefs? (Check all that apply)

[{pr}]

Specify

Is there any curiosity toward your faith or any other faith?

If so, please elaborate:

Is there a plan to further your spiritual growth in the future?

If so, please elaborate:

Add income.

Source of income	Pay Period	Amount	Action

Add benefit.

Benefit	Amount	Action

Add Expense.

Expense	Amount	Action

Total: [{actions.getTotal(viewVars.applicant.expenses)| currency:$:2}]

Were you referred to the Robert Brooks Foundation? If so, could you share who referred you?

[{viewVars.validations.whoReferred}]

Do you give us permission to share your name and contact information with trusted partners who might be able to assist in areas where the Robert Brooks Foundation cannot?

[{viewVars.validations.permission}]

Have you received assistance from our organizations in the past?

[{viewVars.validations.receivedAssistance}]

Are you facing any spiritual challenges that you would like support with, such as prayer or counseling?

[{viewVars.validations.spiritualChallenges}]

please explain if applicable

[{viewVars.validations.spiritualChaInfo}]

Household Members

As you are a previous client you don't need to complete this step. Please submit the form.

Housing Status

Household Type

Adults in Household

[{viewVars.validations.adults}]

Children in Household

[{viewVars.validations.children}]

Seniors in Household

[{viewVars.validations.seniors}]

Estimated Annual Income

[{viewVars.validations.income}]

Any history of child welfare / foster care involvement?

If so, please describe:

Are there any past or current domestic violence issues?

If so, please describe:

Add a Household Member.

Household Member #[{$index+2}]

First Name

Last Name

Relationship

DOB

SSN (Full or Last 4)

Phone

Gender

Ethnicity

Language

[{$item}]

[{k}]

Race

[{$item}]

[{k}]

Health Insurance

[{$item}]

[{k}]

Marital Status

Highest Level Education

Employment Status

Veteran Status

Disability?

School/Daycare Name

Add income.

Source of income	Pay Period	Amount	Action

Total: [{actions.getTotal(child.incomes)| currency:$:2}]

Add benefit.

Benefit	Amount	Action

Total: [{actions.getTotal(child.benefits)| currency:$:2}]

Please add at least one household member.

[{viewVars.title}]

Personal Information

Contact

Household Comments

Race & Language

Education & Employment

Housing

Work

Health

Change

Spiritual

Disclaimer: These questions will not affect your eligibility for assistance from RBF

Income, Benefits & Expenses

Referral

Household Members

Household Member #[{$index+2}]Delete

Household Member #[{$index+2}]