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Mary & Martha House•Apply for Shelter

Intake Form

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Contact Information - Step 1 of 10

Transformation Starts Here.

Please fill out the form below to begin. All information is confidential.

What is your name? *

First

Middle

Last

What is your email address? *

What is the best phone number to reach you? *

What is your date of birth? *

Do you need a Spanish interpreter? *

Yes
No

Are you Pregnant? *

Yes
No
Not Sure

Do you have children? *

Yes
No

How many children do you have? *

Child 1

Child 1 Gender *

Male
Female

Child 1 Age *

Child 2

Child 2 Gender *

Male
Female

Child 2 Age *

Child 3

Child 3 Gender *

Male
Female

Child 3 Age *

Child 4

Child 4 Gender *

Male
Female

Child 4 Age *

Are your children in school/daycare? *

Yes
No

How do you pay for school/daycare? *

Tell us about your current living situation

Are you homeless? *

Yes
No

Briefly explain your situation: *

Are you in Hillsborough county? *

Yes
No

What county? *

For how long? *

Where did you sleep last night? *

Have you ever lived in a shelter? *

Yes
No

Where?

City/County/State *

Length of stay? *

Are you currently employed? *

Yes
No

Where are you employed? *

How long have you been employed? *

Who is your previous employer? *

How long were you employed? *

Highest level of education *

What is your monthly income? *

SSI, SSDI

Child Support

Food Stamps

WIC *

Yes
No

Other Income? *

Yes
No

What and how much? *

Do you have a valid drivers license or Florida identification? *

Yes
No

Do you own a car? *

Yes
No

Is your car registered? *

Yes
No

Is your car insured? *

Yes
No

Identifying Documents

Do you have your birth certificate? *

Yes
No

Does Child 1 have a birth certificate? *

Yes
No

Does Child 2 have a birth certificate? *

Yes
No

Does Child 3 have a birth certificate? *

Yes
No

Does Child 4 have a birth certificate? *

Yes
No

Do you have a social security card? *

Yes
No

Does Child 1 have a social security card? *

Yes
No

Does Child 2 have a social security card? *

Yes
No

Does Child 3 have a social security card? *

Yes
No

Does Child 4 have a social security card? *

Yes
No

Have you ever been arrested? *

Yes
No

What County and State? *

Charges *

Convicted? *

Yes
No

If charges were dropped, do you have paperwork? *

Yes
No

Are you working with an attorney for this or any other situation? *

Yes
No

Have you had an eviction? *

Yes
No

Please explain: *

Can you pass a drug test today? *

Yes
No

Are you taking any medications? *

Yes
No

Please explain: *

Are you a victim of domestic violence? *

Yes
No

For how long? *

Is your abuser actively seeking you? *

Yes
No

Is there a case against your abuser? *

Yes
No

Please answer the following important Covid-19 questions honestly.

Have you been around anyone who has any of the following symptoms in the last 14 days: Sore throat, cough, chills, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100°F? *

Yes
No

Have you or anyone in your household visited or receive treatment at a hospital, nursing home, long-term care, or other healthcare facility in the past 30 days? *