Request for Services
Kingdom Builders Family Life Center
Please Read
We are a program dedicated to serving Black, Indigenous, People of Color (BIPOC), men, young adults, and children from marginalized communities. While our focus is on these groups, we occasionally have space to assist individuals outside of these criteria. Please complete the form below, and a member of our team will reach out to discuss available services and determine how we can best support your needs. If we are unable to provide the necessary services, we will gladly refer you to other resources.
Personal Information
Provide accurate personal information to begin your request.
Name:
*
First Name
Last Name
Age:
*
Gender:
*
Woman (Girl if child)
Man (Boy if child)
Transgender
Non-binary
Other
Pronouns:
*
Zip Code:
*
Primary Race/Ethnicity:
*
Asian
Black/African American
Hispanic/Latino
Native American/Alaska Native
Native Hawaiian/Pacific Islander
White
Middle Eastern
African
Other
If you picked "other" (Please specify):
Email Address:
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Preferred method of contact:
*
Phone
Email
Text Message
Preferred Time for Contact:
*
Morning
Afternoon
Evening
Days of the week you are available:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Household Information
How many people are in your household (including yourself)?
*
Will you have children or dependents joining you?
*
Yes
No
If yes, please provide their ages and any special needs:
*
Safety Information
Are you in a safe place?
*
Yes
No
If not, what immediate assistance do you need to ensure your safety?
*
Service Request Information
What services are you seeking? (Select all that apply):
*
Emergency shelter
Transitional housing
Relocation services
Legal assistance
Counseling/Therapy
Employment assistance
Parenting support
Parenting support
Power Circle Group
Healing & Wellness Group
Other
If you picked "other" (Please specify):
Have you received services from us before?
*
Yes
No
If you picked "yes", please describe the services you received:
When did you last receive services?
*
Victimization History
Have you experienced domestic violence by a romantic partner (like a spouse, boyfriend/girlfriend, former or current)?
*
Yes
No
Have you experienced sexual violence (intimate or non-intimate)?
*
Yes
No
What type of victimization have you experienced? (Check all that apply):
*
Physical abuse
Emotional/Psychological Abuse
Sexual abuse/assault
Financial abuse
Neglect
Other
Other (Please describe):
How long ago did the victimization occur?
How long has it been since the last incident occurred?
*
A week ago or less
More than a week ago but less than a month ago
More than a month ago but less than 6 months ago
More than 6 months ago but less than a year
More than a year ago
Special Circumstances
Do you have any health conditions, disabilities, or other needs that we should consider?
*
Yes
No
If yes, (Please describe):
Employment & Financial Information
Are you currently employed?
*
Yes
No
Do you have any sources of income? (e.g., employment, benefits, child support)
*
Yes
No
If yes, (Please describe):
Additional Information
Will you be bringing your children to your appointments?
*
Yes
No
Will you be bringing a service animal to your appointment?
*
Yes
No
How did you hear about KBFLC?
*
Is there anything else you would like us to know about your situation?
*
By submitting this form, I certify that all the information provided is true and accurate to the best of my knowledge.
*
Submit
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