This form is for clients to fill out for potential Housing or general assistance, Homeless diversion or Homeless prevention. Please know that filling out this form does not guarantee an opening is always available. Once this form is completed we will work to provide you with a referral and/ or assistance.
PLEASE KNOW, THAT YOU WILL GET A REPLY WITHIN 48 HOURS
Phone or Contact #
Email address (for follow-up only)
I need asssistance with... (can check more than 1)
Long or short-term Housing
Services for Women or Women w/ Children
Information about Program
Recovery or Rehabilitation
Address to be released from jail/ prison
a friend or family member
Eviction or Imminent loss of housing
Are you a Veteran?
I have been in this crisis for...
Less than a week
More than a week
I am 30 days Clean/ sober from alcohol or substances
I am currently....
Sheltered (motel, stable roof, program, couch surfing)
Unsheltered (in my vehicle, in the woods, etc.)
Imminent loss of housing
Responding to the needs of another
Incarcerated, ready to be released
Looking for somewhere to donate time or goods
Do you have current Picture ID?
As far as work, I am...
Unemployed, laid off
Under employed (less than 30 hrs. per week)
Not looking for work
Other areas of concern or need are... (can click more than 1)
Family/ relationship issues
Medical/ Mental health assistance
Improving my Education
ID Documentation assistance
Please provide current Zip code to ensure best help
Please provide any additional information about your current circumstances and what caused your hardship that you would like to share. What has changed about your situation that you now need assistance? This will help us identify the most appropriate resources for you and your family.
Can you give me time to evaluate your situation and respond back to you. Would you rather by phone or email?
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