Information Request Form

Information Request
Love INC is unable to meet immediate needs because we are not an "emergency ministry."
Are you a resident of Staunton, Waynesboro, or Augusta County, Virginia?*

YesNo
Unfortunately we cannot serve those outside of Staunton, Waynesboro, or Augusta County, Virginia. Please check our resource directory for other assistance options.
Do you currently have permanent housing? (hotel, shelter, car, or living with someone else temporarily is not considered permanent housing)*

YesNo
Unfortunately we cannot serve those who do not have permant housing. A hotel, shelter, car, or living with someone else temporarily is not considered permanent housing. Please check our resource directory for other assistance options.
If you are a renter, do you have a signed lease?

YesNoNot applicable
Are you currently living in the residence for which you are requesting needs?*

YesNo
The person with need should be the person completing the form. If the person with need requires assistance completing the form, a professional/friend/family member can assist but must include their contact information below.
Do you require assistance in completing this form?

YesNo
Name of person assisting with form (if applicable)

First NameMiddle NameLast Name
Phone Number of person assisting with form (if applicable)
Please enter a valid phone number.
Email of person assisting with form (if applicable)
example@example.com
Relationship to person with need (if applicable)
Name of Person with Need*

First NameMiddle NameLast Name
Have you gone by any other legal name(s) in the past?*

YesNo
If so, what name(s)?

First NameMiddle NameLast Name
First NameMiddle NameLast Name
Phone Number*

Area CodePhone Number
E-mail
example@example.com
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you or anyone in your household been served by Love INC in the past?*

YesNo
Name of person served

First NameMiddle NameLast Name
Have you been served by Love INC in the past 6 months?

YesNo
What is your Preferred Communication?

Phone CallEmail
What are your needs?*

Household itemsFurnitureClothingConnection to a community agencyConnection to a churchFree Bible Based Classes
Explain your needs
Please provide three references. These can be landlord (if renting), personal reference (ex. family or friend) and professional reference (ex. case manager, pastor, employer).
Reference - Landlord
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Reference - Personal
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Reference - Professional
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
What are your prayer requests?
NEXT STEP:

You will receive a call from a Love INC representative that may come up as a restricted/private phone number...please answer!
Please verify that you are human*

Office Use Only
Continue with Clearinghouse
1st date of previous intake (if applicable)

MonthDayYear
Date
2nd date of previous intake (if applicable)

MonthDayYear
Date
3d date of previous intake (if applicable)

MonthDayYear
Date
4th date of previous intake (if applicable)

MonthDayYear
Date
5th date of previous intake (if applicable)

MonthDayYear
Date
Office Notes
Clearinghouse Notes
Should be Empty:

Information Request

The person with need should be the person completing the form. If the person with need requires assistance completing the form, a professional/friend/family member can assist but must include their contact information below.

Please provide three references. These can be landlord (if renting), personal reference (ex. family or friend) and professional reference (ex. case manager, pastor, employer).

NEXT STEP:

You will receive a call from a Love INC representative that may come up as a restricted/private phone number...please answer!