Assistance Request Application

Client Information:

Full Name:

Date Of Birth:

Gender:

Race/Ethnicity (Optional):

Phone Number:

Email Address:

Mailing Address (if applicable)

Identification Verification (Check one if available):

Driver’s License / State ID

Social Security Card

Birth Certificate

None

Current Living Situation (Check one):

Currently Homeless

At Risk of Homelessness

Staying with Friends/Family

Staying in a Hotel

Facing Eviction

Shelter Program

Other

Shelter Name:

Transitional Housing

Other:

Income & Employment:

Monthly Income:

Source of Income (Check all that apply):

Employment

SSI / SSDI

Unemployment

Other:

Currently Employed?

Current Services & Support (Check all that apply):

Are you currently receiving any of the following services?

Mental Health Counseling/Treatment

Provider Name (if known):

Substance Abuse Treatment

Provider Name (if known):

Case Management

Food Assistance (SNAP, food pantries, etc.)

Housing Assistance (Section 8, Rapid Rehousing, etc.)

Medical Care (Medicaid, free clinic, etc.)

Veteran Services

Other:

None

What type of assistance are you seeking? (Check all that apply):

Emergency Housing

Food Assistance

Rental Assistance

Mental Health Resources

Substance Use Resources

Workforce / Employment Resources

Hygiene Supplies

Clothing Assistance

Financial Literacy Assistance

Hotel Stabilization Assistance

Other:

Do you have transportation?

Best way to contact you

Multiselect

Emergency Contact:

Name

Relationship:

Phone:

Consent & Privacy Agreement:

By signing below, I agree that the information provided is accurate. I
understand that my personal information will be kept confidential and used
only for service coordination.

Client Signature:

Date:

Scroll to Top