Intake Form
Ventura County Thomas Fire Long-Term Recovery Group
Client Information
Name *
Your answer
Best Phone Number *
Your answer
Best Time to Call
Your answer
Best Email
Your answer
Co-Applicant / Emergency Contact Name
Your answer
Contact Phone #
Your answer
Relationship to Applicant
Your answer
Applicant's FEMA ID Number
Your answer
Consent to Share Info *
Pre-Disaster Housing Information
Pre-Disaster Housing Information *
Street Address *
Your answer
County of Street Address *
Mailing Address (if different)
Your answer
County of Mailing Address
Your answer
Type of Dwelling *
Current Housing Information
Current Housing Information
Street Address, City, State, Zip Code *
Your answer
County of Street Address *
Mailing Address (if different)
Your answer
County of Mailing Address
Your answer
Risk Assessment
Risk Assessment
If English is not your primary language, please indicate the preferred language
Your answer
Reported Needs
Reported Needs
Client Reported Damage to Primary Residence
Client Reported Damage to Primary Residence
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