QRF Relief Form

QRF Relief Form

Please fill out this form to the best of your ability. Aid is not guaranteed and will be determined on a case by case basis. We are a team localized to specific areas and work as a unit to connect those in need of assistance to resources. We are NOT a crisis intervention team and are volunteers. Please call 911 or 988 if in a mental health or physical crisis. Please allow up to 72 business hours from submission for a response. If application was printed, please take clear pictures of pages and email to: info@fightthewarwithin.org. We do not offer legal advice and are not licensed mental health professionals. You must be 18 years or older to complete this form. To schedule with Fight the War Within directly, schedule a Google Meet here: https://calendar.app.google/Jb5ZURFh3ch1xNJh7
Name of person/people needing relief *

First NameLast Name
Age*
How do you prefer to be contacted?*

CellEmail
Cell (if none, write 000-000-0000)
Please enter a valid phone number.
Email Address
example@example.com
Referring Organization/Person*
Do you have any current thoughts of suicide or homicide?*

YesNo
Do you currently have reliable transportation?*

YesNoI have a ride, if needed
Do you have family that can assist with this situation? Please explain:*
Name and contact information of a battle buddy who we can talk to about this situation (friend, coworker, neighbor). *
Have you requested or received help from this initiative before?*

YesNo
If yes, then when? (Estimated month and year)
Do you have any assets?

HouseVehicle501kCash in bankCollectiblesJewelrySavings
Please fill below names in, if anyone else is impacted by the situation at hand:
Name of person/people needing relief

First NameLast Name
Age
Relationship to Person Requesting Assistance
Name of person/people needing relief

First NameLast Name
Age
Relationship to Person Requesting Assistance
Name of person/people needing relief

First NameLast Name
Age
Relationship to Person Requesting Assistance
Do you have a job?*

Yes- full timeYes- part timeNo
Where do you work? (If applicable)
Are there any pets in the home?*

YesNo
Number of Dogs
Number of Cats
Number of other pets
Names, Breeds, Ages (if marked yes)
Are you currently homeless? (Without stable shelter on a day to day basis).*

YesNoI am about to become homeless
Address (if homeless- skip)

Street Address

Street Address Line 2

CityState

Zip Code
What area are you closest to?*

Bryan CountyEffingham CountySavannah areaStatesboro areaKingsland areaOut of state
Current Needs (mark all that apply)*

Emergency Financial AidCare PackageVA AssistanceEducational Needs (Resources)Homelessness ResourcesMental Health (we are NOT a crisis center- please contact 911 or 988 if in immediate crisis).Domestic ViolenceMST (Military Sexual Trauma)Community Connections (Local Groups and Events)Food Insecurity ResourcesReligious Resources (Connection to a Faith Leader of your preference)Relocation Assistance
If "Emergency Financial Aid" selected, please fill out the following:
How much assistance is needed? *Aid is not guaranteed and requests are not processed the same day of requests*

$100 or less$200 or less$300 or less$400 or less$500-$1,000MoreUnsure
How much total household income do you bring in monthly? (SSA, SSDI, VA, Wages, Child Support, Alimony, Etc.)
Rent/Mortgage
Utilities (Water, electricity, garbage, sewer)
Internet/Cable
Cell Phone
Vehicle
Renter's/Homeowner's Insurance
Vehicle Insurance
Total Credit Cards (Monthly)
Total Loans (Monthly)
Child Support/Alimony (Paid Out)
Life Insurance (Total Monthly)
Health Insurance and Copays (Monthly Total)
Additional Insurances, Total
Subscriptions, Total (Netflix, Spotify, Amazon, etc.)
Food
Gas
Additional Bills/Costs/Month
Total Monthly Living Expenses
Total Monthly Income
What is the timeline of the need of assistance to occur? (PLEASE NOTE that assistance is not guaranteed and is NOT processed the day of requests).*

6 months or longer3-6 months1-3 monthsShorter than 1 month
Professional Background (This will help us pair you to the best fit resources).*

Emergency Medical ServicesFirefighterLaw Enforcement OfficerActive Duty MilitaryRetired MilitaryVeteranSon/daughter of militaryMilitary/Veteran Spouse or Surviving SpouseNone of the above
Organization Affiliation*

American Legion MemberAmerican Legion Auxiliary MemberVFW MemberVFW Auxiliary MemberOtherNone
Please expand on membership, if marked as belonging to an organization.
If a veteran- what was the status of your discharge? (This will not impact assistance from FTWW, however, it may impact assistance from other organizations).

HonorableOther than honorableDishonorableGeneral Under Honorable
Please Upload DD214 (if a veteran)

Cancelof
If a veteran and you did not upload your DD214, please explain.
Do you have any current or past charges? (Including pending- please explain if applicable-will not impact mental health assistance).*
Income (Please list and explain. If income is about to change- please explain).*
What has contributed to or led to this situation?*

Mental Health CrisisLoss of loved one / friendA loss or change in employmentLoss of incomeWaiting on benefits to beginAccident or IncidentA billMedical problems (physical)Relationship Change (separation, divorce, breakup, etc)Transition from Military to Civilian LifeOther
If you are behind on a bill, please upload here:

Cancelof
Other Comments or Information About the Current Situation.*
Consent to sharing of information*

Clear
By signing, I consent to the sharing of my information for the purpose of being connected to appropriate resources. I am 18 years or older. I understand that aid is not guaranteed and will be determined on a case by case basis. This is NOT a crisis intervention team. Please call 911 or 988 if in a mental health or physical crisis. Please allow up to 72 business hours from submission for a response. I understand that this team does not offer legal advice and are not licensed mental health professionals. This initiative has a zero tolerance policy for any form of harassment. Assistance is rendered by volunteers on a need basis. Hours of assistance cannot be guaranteed and are based on the availability of volunteers. Termination of assistance can occur at any time. I agree to the terms that my information can be shared among local organizations and agencies who may assist in my request. GA Code § 10-12-7 (2022)
I agree to the terms above GA Code § 10-12-7 (2022)*

Clear
***For Internal Use Only***
Internal Case Number
Submission Date

MonthDayYear
Date
Crisis / Non Crisis

CrisisNon-Crisis
Should be Empty:

QRF Relief Form

***For Internal Use Only***

For Internal Use Only