Information Request Form

Need Assistance Form - Redirect
We've moved! To make sure your request reaches our Connection Center team, please use the updated form below. It only takes a few minutes, and after you submit it, someone from Love INC will contact you to schedule a phone conversation.

👉 Start the Need Assistance Form - https://www.jotform.com/252808521189159

Questions? Call us at (540) 221-2955.
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?
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)
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?
Are you currently living in the residence for which you are requesting needs?
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?
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.Format: (000) 000-0000.
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?
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
2 digit month, 2 digit day, 4 digit yearDate
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?
Name of person served

First NameMiddle NameLast Name
Have you been served by Love INC in the past 6 months?
What is your Preferred Communication?
What are your needs?
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.Format: (000) 000-0000.
Email
example@example.com
Reference - Personal
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Reference - Professional
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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!
- Continue with Clearinghouse
- 1st date of previous intake (if applicable)
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- 2nd date of previous intake (if applicable)
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- 3d date of previous intake (if applicable)
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- 4th date of previous intake (if applicable)
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- 5th date of previous intake (if applicable)
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Office Notes
- Clearinghouse Notes
- Should be Empty:

Need Assistance Form - Redirect

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!