Get Help Form Assistance Request ApplicationClient Information:Full Name:Date Of Birth:Gender:- Select -MaleFemaleRace/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 NoneCurrent Living Situation (Check one): Currently Homeless At Risk of Homelessness Staying with Friends/Family Staying in a Hotel Facing Eviction Shelter Program OtherShelter Name: Transitional HousingOther:Income & Employment:Monthly Income: Source of Income (Check all that apply): Employment SSI / SSDI UnemploymentOther:Currently Employed?- Select -YesNoCurrent Services & Support (Check all that apply):Are you currently receiving any of the following services? Mental Health Counseling/TreatmentProvider Name (if known): Substance Abuse TreatmentProvider 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 ServicesOther: NoneWhat 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 AssistanceOther:Do you have transportation?YesNoBest way to contact youMultiselectCallTextEmailEmergency Contact:NameRelationship:Phone:Consent & Privacy Agreement:By signing below, I agree that the information provided is accurate. Iunderstand that my personal information will be kept confidential and usedonly for service coordination.Client Signature:Date:Submit Form