Date: ___________________________
Family Name: ______________________________________________________________________________
Phone #:__________________________ Secondary Phone #:__________________________
Monthly Income:_________________________ Income Source(s):_________________________________
Referring Agency: ___________________________________________________________________________
Contact Person:_____________________________________________________________________________
Phone Number:_____________________________________________________________________________
Please note that once this Referral Application is competed and submitted, you will be contacted for an appointment. Please bring the following documents to your intake appointment. Thank you for your referral.
 Recent Income Verification
 Valid IDs
 Birth Certificates for Children
 Social Security Cards
 Resume
 Documentation of Training Program (if applicable)
 Credit and Eviction Report
 Certificate of Homelessness or Letter of Residency (if applicable)
Please fax, mail or email referral application to:
Hamilton Family Center
First Avenues: Housing Solutions for Families
Attention: Homeless Prevention Case Manager
(415) 614-9062 (fax)
Please contact a Homeless Prevention Case Manager to answer any questions:
(415) 614-9060 ext. 101, ext. 102, ext. 109, ext. 107 or ext. 108
1 255 Hyde, San Francisco, CA 94102
415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org

Adults Living in Household:
Name
(List Head of Household First)
Social Security Age DOB Relationship
(to Head of Household)
Children and/or Dependents Living in Household (Must have custody of minors under 18):
Name Sex Relationship
(to head of household)
Age DOB In School/
Childcare?
Name of School/
Childcare
List any children not in custody:
Name Relationship DOB Where do they live?
Current Address or shelter name:________________________________________________________________
If homeless, briefly explain the circumstances that brought the family to homelessness?______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How long has the family been homeless?_________________ Is this the first time they are homeless? Yes No
What is the date the family became homeless?_____________________________________________________
Other homeless shelters/programs/services used by the family:
(please include all rental assistance/subsidy programs that you have ever used)
Agency/Shelter/Program Name Dates
2 255 Hyde, San Francisco, CA 94102
415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org

Rental History:
List Housing History for the past 3 years:
Address Rent Amount Paid Per Month Dates
Does the family have any evictions? Yes No If yes, please explain (dates, circumstances, etc).___________
__________________________________________________________________________________________
Has the family had a lease in their names? Yes No If yes, when and for how long?__________________
Does the family have significant credit barriers to obtaining housing? Yes No If yes, what? Any housing related debts (utilities, evictions, etc.)___________________________________________________________
Is the family working to pay off or consolidate debts? Are they working with a credit counselor?_______________
__________________________________________________________________________________________
Employment History:
List your most recent employment position & company: _____________________________________________
How long were you at that company? __________________________
Reason for leaving? __________________________________________________________________________
Month/Year that you left that company: __________________
What is the longest length of time that you have stayed at one company? ________________________________
Position title/company: ______________________________________________________
Reason for leaving ____________________________________________________
Month/Year that you left that company: __________________
3 255 Hyde, San Francisco, CA 94102
415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org

Do you have professional references available? Yes No
Education History
What was your highest grade completed? ________________________________________
Please list all certificate, training programs or classes you have completed
1. _______________________________________________________ Date: __________________
2. _______________________________________________________ Date: __________________
3. _______________________________________________________ Date: __________________
Current Family Income:
Do you currently receive Food Stamps? ________ If yes, please list amount $: ____________
Income Source Amount
SSI
SSDI
CalWORKs
Employment/Unemployment
Child Support
GA
Other (please list source):
Total Monthly Cash Income (please list gross, take-home income, include undocumented income)
50% of Total Monthly Cash Income
If all or part of income is CALWORKS, please complete the following:
CALWORKS Status: Welfare to Work Exempt Sanctioned
If exempt or sanctioned, please explain (when and for how long) ______________________________________
4 255 Hyde, San Francisco, CA 94102
415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org

Chemical Dependency/Alcoholism History
1.) Is anyone in the family actively using? Yes No
2.) If anyone is in treatment/recovery, where and for how long? (Please be very specific about length of recovery time)______________________________________________________________________________________
__________________________________________________________________________________________
History of Domestic Violence
1.) Does the family have a history of domestic violence? Yes No
If yes, Indicate length of time away from abuser. __________________________________________________
2.) Any restraining orders? Yes No
3.) Any formal support, i.e. DV shelter, support groups?_____________________________________________
Criminal History:
Do any adults in the household have a felony? Yes No If yes, for what and when? ____________________
__________________________________________________________________________________________
5 255 Hyde, San Francisco, CA 94102
415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org

Please list at least 3 steps to increase your family income within 3-24 months. Provide details when necessary.
Plan A: _________________________________________________________________
Action required: __________________________________________________________
Expected time to reach goal: _______________________________________________
Additional information: ______________________________________________________________________
__________________________________________________________________________________________
Plan B: _________________________________________________________________
Action required: __________________________________________________________
Expected time to reach goal: _______________________________________________
Additional information: ______________________________________________________________________
__________________________________________________________________________________________
Plan C: _________________________________________________________________
Action required: __________________________________________________________
Expected time to reach goal: _______________________________________________
Additional information: ______________________________________________________________________
__________________________________________________________________________________________
I hereby verify that all the information provided is true and accurate to the best of my knowledge.
_____________________________________
Signature
_____________________________________
__________________
Date
__________________
Signature Date
6 255 Hyde, San Francisco, CA 94102
415/ 614-9060 fax 415/614-9062 www.hamiltonfamilycenter.org