Assistance Request Application

Applicant's Information:

Full Name:

Date Of Birth:

Gender:

Race/Ethnicity (Optional):

Phone Number:

Is it safe to call, text or leave a voicemail at this number?

Yes

APPLICANT's Email Address:

Mailing Address (if applicable)

Identification Verification

Do you currently have any form of identification? Check all that apply.

Driver’s License / State ID

Social Security Card

Birth Certificate

None

Current Living Situation

Which best describes your current living situation?

Currently Homeless/Sleeping Outside

Staying in a vehicle

Staying with Friends/Family

Staying in a Hotel

Facing Eviction

At Risk of Homelessness

Currently in a shelter program

Currently in transitional housing

Shelter or program name, if applicable:

Are there children currently with you or in your care?

Yes

Number of adults in household:

Number of children in household:

Income & Employment:

Monthly Income:

Are you currently employed?

Yes

Are you interested in employment or job readiness resources?

Yes

Current Services & Support

Are you currently receiving any of the following services? Check all that apply

Mental Health Services

Substance Use Treatment/Support

Case Management

SNAP / Food Stamps

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

Medical Care (Medicaid, free clinic, etc.)

Veteran Services

None

Other:

If you are currently working with a provider, case manager, counselor, or agency, please list their name and contact information. N/A is NOT an answer. Please provide requested info. Add none if not working with anyone.

Referred By: Please provide the name and contact information of who referred you to URP. (If no one put none)

Are there any medical conditions (physical or mental) that we should be aware of?

Does the applicant have any history of sexual or physical violence?

Yes

If yes- please provide more details

Is there anything else we should know about this applicant?

Type of Assistance Requested

What type of assistance are you seeking? Check all that apply.

Emergency Housing ( A bed in our transitional house )

Food Assistance

Hygiene Supplies

Clothing Assistance

Mental Health Resources

Substance Use Resources

Job/Employment Resources

Financial Literacy Assistance

Other

Please briefly explain what you need help with

Do you have transportation?

Yes

Are you able to get to URP if offered a bed or assistance?

Yes

Best way to contact you

Phone

Both

Emergency Contact:

Name

Relationship:

Phone:

You must check ALL boxes

I understand that submitting this form does not guarantee assistance, services, or bed placement.

I understand that I must monitor my phone for a call, text, or email to discuss my request.

I understand that emergency beds are limited and may not be available at the time of my request.

I understand that if I am offered an emergency bed, I must report for check-in between 3:30 PM and 6:30 PM.

I understand that emergency bed placement is for THREE nights only, and checkout is at 12:00 PM on checkout day.

I understand that beds are available on a first-come, first-served basis and that if I do not arrive within 30 minutes of my assigned check-in time, I may lose my bed.

I understand that I may not bring more than 2 bags.

I understand that URP’s transitional home is for adults only and children are not allowed on site.

Additional Notes (Example if this is a postdated form)

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: