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MI AECRES Intake Form
If you are interested in working with an advocate, please complete this form to the best of your ability. An advocate will follow-up with you within 2-3 business days.
DISCLAIMER: FILLING OUT THIS FORM DOES *NOT* MEAN YOUR CASE HAS BEEN ACCEPTED FOR SERVICES AND/OR REPRESENTATION. WE WILL REVIEW YOUR CASE AND LET YOU KNOW IF AND WHAT SERVICES WE ARE ABLE TO PROVIDE. WE WILL ALSO REVIEW TO DETERMINE YOUR ESTIMATED COST FOR SERVICES, OR IF YOU QUALIFY FOR FREE SERVICES. SERVICES COMMENCE ONLY AFTER SIGNING AN AGREEMENT FOR SERVICES CONTRACT. THOSE QUALIFYING FOR FREE SERVICES WILL NEED TO SUBMIT VERIFICATION OF INCOME.
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* Required
Parent or Guardian Name
*
Your answer
Phone Number
*
Your answer
Able to text?
*
Yes
No
Mailing Address
*
Your answer
Email
*
If you do not have an email address, please put "N/A"
Your answer
Communication preference
*
Phone Call
Text
Email
Are you able to participate in video calls?
*
For example: Zoom, Ring Central, Google Meets, etc.
Yes
No
How many individuals are in your household? (# adults, #children)
*
Your answer
What is your total monthly income, from all sources?
*
Your answer
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