Connections of Cumberland County New Client Screening Form

Connections of Cumberland County operates a Day Resource Center for Women and Children who are experiencing housing insecurity in Cumberland County. To learn more about our programs and COVID-19 Response and Protocol, please visit

During the COVID-19 crisis, we have transitioned to a virtual service model to deliver case management and other supportive services. Please utilize this form to connect with a case manager. Upon receiving your inquiry, we will be in contact with you within 24 to 48 hours via email to schedule a ZOOM conference meeting or telephone call to discuss your individual needs. Please be patient with our Team as our referral protocol looks very different than it has in the past. There may be disruption of services or depletion of resources at other organizations as they develop their own protocol to prevent the spread of COVID-19. Our Team remains committed to reducing wrong doors in the community and will make our best attempts to stay informed of changes or reduction of service among referral agencies.

There is an unprecedented need for eviction prevention and utility disconnect prevention in our community. Due to the volume of requests for financial assistance, once you have submitted your form, please forward verification of the following to with the subject line FINANCIAL ASSISTANCE REQUEST, and your last name, first initial:

REQUIRED: Entire lease agreement and utility bill must be in the name of the individual making the request. Please scan or take clear photos of all documents before forwarding.

REQUIRED: Verification of income. Our funder requires your last two months of pay stubs or other verification documents for unearned income. All income coming into the home (employment, child support, unemployment, SSA/SSI, SNAP, etc) must be verified. If you are unemployed or working reduced hours due to COVID-19, we strongly encourage you to apply for unemployment benefits and create a profile with NC Works Career Center. This assistance from Connections is one time only and due to unprecedented community need, you may experience challenges finding funding sources from non-profits, churches and other agencies to help fill the gaps in the coming months. A member of our Case Management Team will also provide you information on employers who may be presently hiring in our community.
Email address *
First Name, Last Name, and Date of Birth: *
Telephone number: *
Please provide your physical address: *
Describe your reason for Contacting Connections (please be specific) and list who referred you : *
List other agencies you have contacted to address your need and how they were able to assist your family: *
Current Living Arrangement: *
How long have you been in the above living arrangement: *
List the names, ages and dates of birth of all individuals living with you: *
What is your current employment status: *
What is your current income (please describe monthly gross income from employment, SNAP, child support, SSI/SSDI, or other monetary source? Income verification is required for financial assistance if funding is available. *
Would you like to receive employment related news via email on potential employers hiring during the COVID-19 crisis? *
Please share how COVID-19 has impacted your family? *
Do you have computer and internet access? *
Would you be interested in connecting to Zoom Meetings for any of the following? *
A copy of your responses will be emailed to the address you provided.
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