UWC Assessment

All community members accessing UWC services will need to complete this form. You will be asked to upload a copy of your government-issued identification. (This is not an option, if we don't have an ID with your application it will be denied). Required. Our services are only for Trans and Non-Binary identified community members in Los Angeles County and surrounding cities.
Once you complete this assessment, you will be contacted to set up an appointment to continue the assessment.
2. Legal Name: (on your government issued ID)
1. Email address *
If you need assistance with changing your name and or gender please indicate that in the notes. We can help.
3. Chosen Name (if different from legal name)
Our services are open to Transgender and non-binary identified communities only.
How do you identify?*

Trans Masculine - Trans ManTrans Feminine - Trans WomanNon-Binary
What are your pronouns?

Non-BinaryHe / HisShe / Her
Is your housing temporary or permanent?

TemporaryPermanent
You will be asked to upload a copy of your ID at the end of this form (NO EXCEPTIONS
Do you have valid identification?

YesNo
Do you have a social security card?

YesNo
Do you have a birth certificate?

YesNo
Do you have transportation?

YesNo
Do you have a bus pass?

YesNo
Do you know your HIV Status? (yes/no)
Do you know your HIV status?*

NegativePositiveI do not know my status
Have you been diagnosed with any disabilities?

YesNo
Are you on probation or parole?

YesNoParoleProbation
Do you have health insurance?

YesNo
If you have health insurance, is it private or Medi-Cal?

PrivateMedi-CalI don't have health insurance
Are you currently receiving General Relief ( GR) ?

YesNo
18. If you're not receiving Genera Relief, what is your source of income?
Do you need help accessing any of these items? Health insurance, social security, general relief, food stamps, life insurance?

YesNo
Which service do you need assistance with?

Social Security CardHelp with applying for General Relief or Food StampsHealth Insurance / Medi-CalBirth CertificateI don't need this service
Do you have access to food?

YesNo
If you don't have access to food, please visit our website and click Community Resources to find a food bank.
22. Please tell us what are your emergency needs? (we do not give out money) *
23. Please tell us how you are impacted by COVID 19?
How long have you been impacted by COVID-19?

30 days or less1 month - 3 months90 days or more
25. What emergency assistance other than money can help you right now? (if you don't need emergency assistance, type NA) As a reminder, we do not offer cash *
Do you meet all the requirements to apply?*

YESI do not qualify for this fund
Do you need emergency assistance?*

YesNo
29. Mobile Phone Number **
What is your ethnic background?*

Black or African AmericanAmerican Indian or Alaska NativeAsianHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteMixed Heritage
30. Your complete mailing address including city and zip code; you must live in Los Angeles County) No Exceptions*
31. Date of Birth **

MonthDayYear
Date
32. Your Current Age
33. Cash App Handle **
34. How did you hear about this emergency relief fund? *
35. Have you participated with our organization previously? If so tell us about it *
You will need to upload a picture of your identification, You can also bring it with you to your appointment
upload your identification here ( a picture of your ID is ok)*

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You will need to upload a picture of your identification, You can also bring it with you to your appointment