ICSB Social Services Intake Form

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Any Information provided below are confidential and will not be shared with any other party. Please complete the form and our office will reach out to you within 3-5 working days.

Email *

First Name *

Last Name *

Date of Birth *

YYYY

City of residence (At this time our services are limited to the following cites only) *

Lomita

Torrance

Harbor City

Carson

Gardena

Beach cities

San Pedro

Wilmington

Required

Address: Street Address *

City *

Zip code *

Phone Number *

Email *

Are you the head of your household? *

Yes

Marital status *

Name of spouse (if applicable) *

Dependents *

Yes

Name and Age of dependents *

Occupation *

Education level *

What is your current income? *

Do you receive government assistance? *

Yes

If yes, what government assistance do you receive? *

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