DO YOU NEED A PLACE TO STay? Complete this Unhoused Youth Services Referal Form!

Complete this form and someone will reach out to you in the order it was received. Please understand, that filling out this form does not guarantee bed availability but guarantees support on this journey.

What Can we help with?

Emergency Housing Resource Navigation
Career & Education Support
Permanent Housing Search Support
Access to mental health counseling

What can you expect?

Complete a New Member orientation
Easy Booking for appointments on your schedule
Flexible Progress Meetings and goal-setting sessions

The following are the minimum eligibility requirements for a young person to receive Unhoused Youth Services:

● Unaccompanied Youth - 24 years of age or younger, Not in the physical custody or care of a parent or legal guardian, and Lacks a fixed, regular, or adequate nighttime residence.

● A current resident of Wicomico, Somerset, Worcester

Please Note: ALL INFORMATION ON THIS FORM WILL BE TREATED CONFIDENTIALLY. No person or agency, other than yourself, will be contacted without your knowledge and consent.

Name

First Name

Last Name

Do you go by any other names? If so, please enter below

Gender

Age

Phone

(###)

###

####

Alternative Number

(###)

###

####

Birthplace City/State

Current Status

Most Recent Living Situation

Background Information

IF UNDER 18: Are you legally emanacipated? If yes, please share date of Emacipation; If No, Provide Name/phone of Legal guardian

If over 18, please type N/A

Do you have children? If yes, please provide child's name, gender and birthdate

Have you ever been arrested or in trouble with the law? If yes, describe below

Do you have any charges pending? If yes, describe below

Do you have any upcoming court dates? If yes, please describe below

Are you currently on probation or parole?

Are there any outstanding warrants for your arrests?

Are you AWOL from a court-orderd placement and not in contact with your worker? If yes, explain below

Have you ever been charged for criminal sexual conduct? If yes, please describe below

Personal Statements

Entering the Fenix Youth Project Chosen Family Host Home program is designed to focus on the longer-term needs of homeless youth that are harder to address in a crisis shelter setting. This is a semi-independent, life-skills-based, housing program. The following personal statements will help us determine your willingness to complete the 6-step program. Please make your statements AT LEAST 25 words in length. Please use additional paper if needed. If you need assistance feeling this out, please call our office and we will be happy to write your statement as you share your answers

Personal Statement: FYP provides a stable, semi-independent living situation for people who do not have other options for a place to live. Please describe your current situation and how it developed

If you are accepted, we will be providing you with a stable place to live while you work on creating your own independent living situation.

Please describe. A. What your future plans are B. How living here fits in with those plans C. What do you plan to do while you are here D. How long you will need to live here

Housing Status: (Check One)

Literally Homeless: Places not meant for human habitation, shelter, or transitional housing last night, exiting institution following homelessness or a survivor of domestic violence

Housed and at imminent risk of losing housing: Evicted, discharged from hospital/institution with no place to go, and condemned housing with no subsequent housing and inadequate resources

Housed and at-risk of losing housing: At risk due to high housing costs, conflict, or other conditions that put housing at risk and inadequate resources. The danger is not immediate

Stably Housed: Not at risk of losing housing

Don't Know

DO YOU NEED A PLACE TO STay? Complete this Unhoused Youth Services Referal Form!

What Can we help with?

Emergency Housing Resource Navigation

Career & Education Support

Permanent Housing Search Support

Access to mental health counseling

What can you expect?

Complete a New Member orientation

Easy Booking for appointments on your schedule

Flexible Progress Meetings and goal-setting sessions

Please Note: ALL INFORMATION ON THIS FORM WILL BE TREATED CONFIDENTIALLY. No person or agency, other than yourself, will be contacted without your knowledge and consent.

Show your support

Help us keep the promise of a better community for all