Refer a local need (Warren county NC and surrounding)
This information is kept confidential, we will determine if we are able/how best to address the need/crisis referred. You choose whether you wish be informed of our outcome if you would like to be informed. Also please choose whether you wish to remain anonymous, in which case we won't share your information but we do require it for our internal confidential records and in the event we need to get more information.
Your contact number (with area code)
Do you mind if we share who referred us to assist the person(s) in need?
I do not mind you sharing this information if it is requested/will help with meeting the person(s) need.
I wish to remain anonymous.
Name of the person(s) in need/crisis
Address of person(s) in need/crisis
Phone number of person(s) in need/crisis
Nature/type of the assistance needed
Food crisis (lack of groceries, requiring assistance in preparing meals)
Transportation (needing rides to any sort of needed place, Dr, shopping,etc)
General well being / emotional encouragement
How many person(s) and approx ages
Other/notes/also (Anything you wish to add feel free to put it here)
Do you wish to be contacted regarding our outcome on this matter?
Yes please contact me
No I don't wish to be informed
Be on notice that we can't promise that we can assist with every need, nor that everyone offered assistance will accept it. We will do our best to address the need brought forward. We do so without discrimination based on any factors, and seek to alleviate needs as best we can, but don't offer assistance in ways that contribute to harmful outcomes. We not able offer cash assistance. You understand accept these conditions.
I understand and agree to the above conditions.
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