Resource Request Intake Form

All requests are initiated by a partnering agency via email. The intake form must be completed and sent to sylvia@jamessamaritan.org. This form may also be found on our website under the "caseworker" tab at www.jamessamaritan.org. The intake form must be completed in order to receive assistance. Completing the form is NOT a guarantee of  assistance. 

Note 1: James Samaritan exists to provide support and services to the foster care community. In order to continue serving this community for years to come, it is necessary to limit the distribution of resources to individuals who are currently involved in the foster care system or currently being cared for by a relative.

Note 2: James Samaritan is NOT able to accept requests that are urgent in nature. Requests for housing, rental assistance, utilities, transportation, and other urgent needs or ongoing needs will not be considered as we do not have the capacity to meet needs at this level.

Note 3: James Samaritan will review the request upon receipt of the intake form and respond to the referring agency regarding James Samaritan’s ability to meet the requested need. 

Thank you for your dedication in serving children and families from hard places. We appreciate any feedback you may have about this process or about how James Samaritan has impacted a client in a positive way. All feedback is helpful to us as we continuously strive to improve and is a great encouragement to those who support and fund our organization.


Email *
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/
DD
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Referring Agency *
Caseworker Name *
Caseworker phone number and email address *
Parish or Region *
Caregiver's Name, Address, and phone # *
Race or Ethnicity (check all that apply) *
Required
This Placement is a *
Required
Please describe the type of assistance you are requesting below (BE VERY SPECIFIC-include sizes for bed, specify who will be using this resource, etc.): *
Please describe the special circumstances that prompted you to request this assistance. What is the hardship? What lead to this becoming a need? *
Will this resource help facilitate or maintain a kinship placement? *
Required
Will this resource help facilitate a foster youth in achieving independence? *
Required
Is this client/family currently enrolled in any other program to assist with these needs? *
Required
Person(s) receiving the resources-name, age, and relationship to the caregiver: *
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