Camp Fire Intake Form
The Camp Fire Long Term Recovery Group (Camp Fire LTRG) is a collaboration of organizations working to address unmet needs of fire survivors. Butte 211 helps connect survivors to resources that address immediate needs as well as the services that offer assistance with long term recovery. Please complete this Intake Form to be considered for disaster case management, financial assistance programs, basic needs, and other fire recovery programs. A Butte 2-1-1 Outreach team member will contact you to discuss your needs and connect you to resources and assistance for which you may be eligible. Certain documentation may be requested later to confirm eligibility for specific programs.
* Required
First Name
*
Your answer
Last Name
*
Your answer
Best Phone Number:
*
Your answer
2nd Phone Number
Your answer
Email Address
Your answer
Gender
*
Your answer
Date of Birth
*
Your answer
What is the best way to reach you?
*
E-mail
Phone
Other:
Required
What is the best time to contact you?
Morning 7:30am to 12 Noon.
After 12 Noon to 6:00 pm.
Saturdays
Anytime.
Do you already have a case manager that you are working with currently for your recovery from the Camp Fire?
*
Yes
No
Not sure
Other:
Do you consent for your information to be shared with other agencies such as disaster case management services and financial assistance programs to help Camp Fire Survivors meet their immediate and long term needs? (This includes agencies operating under the Long Term Recovery Group coordination such as Caring Choices, United Way, Youth for Change, Northern Valley Catholic Social Services, Jesus Center, Tzu Chi, St. Vincent de Paul, North Valley Community Foundation, and others.)
*
I consent.
I do not consent. (Please note that consent is required for your information to be shared with agencies providing disaster case management and financial assistance.)
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