Apply - Homeward Bound

Please Note:

Homeward Bound is NOT a shelter. If you need emergency assistance call
CONTACS – Community Network for Accessing Shelter at 602.263.8900.

If you are interested and willing to participate in a program that includes supportive counseling, budgeting and class work, please complete this form or call our intake coordinator at 602.263.7654.

Intake Inquiry

THIS IS NOT AN APPLICATION - it is a pre-assessment for eligibility. Completing this inquiry is the first step toward a new beginning for you and your family. Please complete this form and an intake coordinator will contact you shortly.

Contact Information
Please let us know how to get in touch with you.
Name*
FirstLast
Phone*
Email
Second Adult
If you are applying with another adult, please fill out the information below.
Name
FirstLast
Phone
Email
About You
Please tell us about your situation.
1. Are you homeless, facing homelessness or fleeing domestic violence?
- Yes
- No
Explain:
2. Do you have children residing with you?
- Yes
- No
If yes, how many?
What is the age(s) and gender of your child(ren)?
3. What is your current employment/income status?
4. What type of income do you currently receive? (Employment, cash assistance, SSI, SSDI, unemployment, etc.)
5. How much do you receive?
6. Have you ever been convicted of a violent crime?
- Yes
- No
Explain:
7. Do you have any history of substance abuse (alcohol and/or drugs)?
- Yes
- No
Explain:

Please Note:

Intake Inquiry

Contact Information

Second Adult

About You