2. Parent name (Head of Household)*
   Please clearly print first and last name
3. Today's date*
5. Telephone number of client*
6. Referring agency*

   1. Arapahoe/Douglas Works!
   2. CWEE
   3. Aurora @ Home
   4. Aurora Public Schools
   5. Cherry Creek Public Schools
   6. Arapahoe County Human Services
   7. Other
10. 1. Eligible to receive benefits in Arapahoe County?*

    1. Yes
    2. No
11. 2. Currently receive benefits from Arapahoe County?*

    1. Yes
    2. No
12. 3. Currently homeless?*

    1. Yes
    2. No
14. 4. Currently has unstable housing/at-risk of homelessness?*

    1. Yes
    2. No
15. 5. Adult has at least one child under the age of 18 in their custody or is currently pregnant?*

    1. Yes
    2. No
16. 6. Is the household income less than $75,000/year?*

    1. Yes
    2. No
18. 7. Is anyone in the household receiving disability benefits?*

    1. Yes
    2. No
19. 8. Does the family agree to live in congregate housing?*

    1. Yes
    2. No
20. 9. Does family agree to live in a drug-free environment?*

    1. Yes
    2. No
22. 10. Does family agree to participate in GOALS programming?*

    1. Yes
    2. No
26. Please ask family if they identify with the following statements:
28. I've been thinking I might want to change something about myself to improve the quality of my life.*

    1. Yes
    2. No
29. I am hoping to participate in a process that will help me to better understand myself.*

    1. Yes
    2. No
33. Screening Tool
    Arapahoe County has partnered with the Family Tree to provide temporary housing and services for families who are struggling with homelessness. This program provides services for parents, children, and families as a whole by providing safe stable housing, meals, and a variety of on-site services, including: on-site childcare; health screenings; mental health services; employment services; and classes and workshops. If you're interested in potentially enrolling in this opportunity (you may change your mind later), I just need to collect some information about the members of your household so that I can refer you to the program. You’ll then be contacted by the program director, who will call you let you know about their availability and answer any questions you might have about the program.
35. Name of Head of Household*
36. Member is *

    1. Adult
    2. Child

    Check one
37. Age of head of household*
39. Name of family member #2
40. #2 member is

    1. Adult
    2. Child

    Check one
41. Age of member #2
43. Name of family member #3
44. #3 member is

    1. Adult
    2. Child

    Check one
45. Age of member #3
47. Name of family member #4
48. #4 member is

    1. Adult
    2. Child

    Check one
49. Age of member #4
51. Name of family member #5
52. #5 member is

    1. Adult
    2. Child

    Check one
53. Age of member #5
55. Name of family member #6
56. #6 member is

    1. Adult
    2. Child

    Check one
57. Age of member #6
59. Total number of adults in the household*
60. Total number of children in the household*
62. Client's current address
    If available
64. Client's phone number*
65. OK to leave a voicemail/text?*

    1. Yes
    2. No
67. Alternate phone number
68. OK to leave a voicemail/text

    1. Yes
    2. No
70. Emergency contact (name)
71. Emergency contact (phone number)
73. Case identified by*
74. Client's primary language*
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field