Family Service Request Form

Are you a family who is currently experiencing homelessness or at risk for becoming homeless?

Please complete the Family Service Request form below and the information will be directed via e-mail to a Family Service Navigator at your nearest Access Point (location where a family receives support and referrals to appropriate housing options).

Families may be eligible to receive the following Housing services:

Rental Assistance
Referrals to Shelter
Navigation and referrals to Housing Programs
Referrals to other supportive services (food pantries, mainstream benefits, healthcare, etc.).

Access Points are not emergency services. Please allow up to two (2) business days for an Access Point to contact you after submission of the Family Service Request form.

Terms*
By submitting this online form, I give permission to share my information contained in this form with the Family Solutions Collaborative and Family Access Points. This form and its data will be sent via email to a Family Service Navigator at a Family Access Point. I understand that the submission of this form does not guarantee services or financial assistance, and that I may receive assistance from a similar or comparable program. I certify that the information I provide on this form is true, correct and complete.
- I agree
- I do not agree
Please dial 2-1-1 and request to be connected to a CES Access Point.
Eligibility
Are you currently experiencing a health or physical safety emergency?*
- Yes
- No
If you have a health emergency or are in a life threatening situation (including domestic/dating violence, sexual assault or stalking) call 911 immediately.
Are you currently residing/staying in Orange County, CA?*
- Yes
- No
Please dial 2‐1‐1 to be connected to services in your community.
City*
What is your Irvine zip code?*
What is your Santa Ana zip code?*
What is your Anaheim zip code?*
Are you, or is anyone in your household, a Veteran of the U.S. Military (any discharge status)?*
- Yes
- No
- Do not know
- Decline to answer
Is anyone in the family currently pregnant?*
- Yes
- No
Do you have any minor children in your care?*
- Yes
- No
Are you in the process of reunifying with any minor children?*
- Yes
- No
Please dial 2‐1‐1 to be connected to services in your community.
Please dial 2-1-1 and request to be connected to a Veteran Access Point.
How many minor children (17 or younger) are in your household, including those that you may be in the process of reuniting with?*
- 0
- 1
- 2
- 3
- 4
- 5 or more
Including you, how many people in your household are 18 or older?*
- 1
- 2
- 3
- 4
- 5 or more
Head of Household Information
Name*
First Last
Gender*
- Female
- Male
- A gender other than singularly female or male (e.g., non-binary, genderfluid, agender, culturally specific gender)
- Transgender
- Questioning
- Do not know
- Decline to answer
Race*
Select all that apply
- American Indian, Alaska Native, or Indigenous
- Asian or Asian American
- Black, African American, or African
- Native Hawaiian or Pacific Islander
- White
- Do not know
- Decline to answer
Ethnicity*
- Hispanic/Latin(a)(o)(x)
- Non-Hispanic/Non-Latin(a)(o)(x)
- Do not know
- Decline to answer
Primary Language*
- English
- Spanish
- Vietnamese
- American Sign Language
Primary Phone Number*
Alternate Phone Number
Email
Enter Email Confirm Email
When is the best time to reach you?
Select all that apply
- 8am - 11am
- 11am - 2pm
- 2pm - 5pm
Where did you stay last night?*
- In our own apartment/house
- In someone else's apartment/house
- In a motel that we pay for ourselves
- In a motel that is paid for by an agency
- In a shelter or transitional housing
- In a residential garage or shed
- In a car, recreational vehicle, trailer, etc.
- Outdoors, in a park, in a tent, etc.
Would you like to receive an email confirmation that this form has been successfully submitted to an Access Point?*
- Yes
- No
Confirmation of form submission sent to*
Email address Confirm email address
Comments
This field is for validation purposes and should be left unchanged.

Family Service Request Form

Are you a family who is currently experiencing homelessness or at risk for becoming homeless?

Eligibility

Head of Household Information

Subscribe to the FSC Newsletter