Disaster Intake Assessment
Basic information required for follow-up
Email address *
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Your answer
First and Last Name *
Your answer
Disaster Damaged Address *
Your answer
Parish of Disaster Damaged Residence *
Your answer
Current Physical Address *
Your answer
Current Residing Parish *
Your answer
Best contact number *
Your answer
Do you presently own or rent? *
If you are a home owner, have you taken the Restore Louisiana survey? *
Are any children under the age of 18 in the home? *
Are any household residents 65 years of age or older? *
Are any household residents considered legally disable? *
Do you know your FEMA Registration Number? *
What type of services are you requesting? *
What is your current employment status? *
Please confirm your disaster assistance received to date: *
How did you hear about us? *
Your answer
A copy of your responses will be emailed to the address you provided.
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