Project FAM Referral Form
PLEASE READ BEFORE FILLING OUT THE FORM: This is a general project referral form for the community. Please feel free to share whatever feels comfortable to you with regard to why you are seeking a referral to Project FAM services.

**Note: WE DO NOT directly provide ALL of the below services depending on our current capacity, but WE DO provide navigation and referrals for a lot of these supports and services across the Durham community. Unfortunately, we DO NOT PROVIDE  EMERGENCY HOUSING, FINANICAL ASSISTANCE, CRISIS RESPONSE, or EMERGENCY RENTAL ASSISTANCE .  If you are seeking EMERGENCY HOUSING please check out this resource list provided from Durham County Community Resource Assistance Guide (ncworks.gov) or call 211!

*****Case Management is out of the office Wed 10/30 to Monday 11/4 and therefore will not respond to any requests for support during that time******


Sign in to Google to save your progress. Learn more
Email *
Name *
Phone number to contact you? *
Pronouns *
Required
Age *
Do you identify as a part of the LGBTQ community? *
Do you identify as a part of the Black, Indigenous, People of Color community? *
Which gender best describes your identity? *
Which services are you seeking a referral to? *
Required
Can you describe more about what kind of support you are looking for or your situation?
Are you safe in your current living situation? If not, can you share more about that?
Is it safe to call/text/email you currently? If not, how would you like follow up to happen?
Where are you located?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of The LGBTQ Center of Durham, Inc. Report Abuse
Google Forms