Project Independence Inquiry
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Spouse/Partner/Roommate Name
First Name
Last Name
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Household Type
*
Single/One Individual
Single Parent Household
Married/Multiple Adult Household
Married/Multiple Adult Household w/ Children
Multiple Generational Household (ex. Grandparents/Parents/Children
Housing Circumstances
*
Rent
Own/Mortgage
Family/Friends Housing
Couch Surfing
Homeless
How many adults, 18 or older, live in the house?
*
Including you, how many total people in the house?
*
Transportation Circumstances
*
Have Reliable Transportation
Have Transportation
No Transportation
Other
Employment Circumstances
*
Employed Full Time
Employed Part Time
Multiple Jobs
Unemployed (3 Months or less)
Unemployed (4 or more months)
Other
Are you only seeking financial assistance from Project Independence?
*
Yes
No
What is the household's first language?
*
English
Spanish
Shoshone/Arapahoe
Other
Do you have problems communicating with others?
*
Yes
No
Do you have consistent access to the internet with a phone or computer?
*
Yes
No
Please rank your current need in the following categories:
*
No Need
Somewhat Needed
Need
High Need
Emergency Situation or Immediate
Housing
Rent/Deposit
Utility Assistance/Deposit
Medical Care/Dental/Vision
Food Security
Transportation
Life/Parenting Skills
Employment
Child Care
Mental Health Resources
Use/Addiction Help
Domestic Violence Resources
Debt/Behind on Bills
Creating Better Habits
Breaking Generational Chains of Poverty
If Project Independence is unable to help with financial assistance, are you willing to work with a Case Manager in obtaining self-sufficiency?
Yes
No
What do you believe Project Independence can do for you and your family?
*
Do you have any legal issues, history or arrests and/or incarcerations, probation/supervision, or parole? If yes, please explain:
*
Have you ever been charged or convicted of a felony? If yes, please explain.
*
Who are you being referred to us by?
Please verify that you are human
*
Submit
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