CONNECT Intake

1
Intake Type
Please Select
Please Select
General
Flex Fund Support
External Partner Referral
2
Referral Source
Please Select
Please Select
TND
Greater Boston Legal Services
tCoC
CAPIC
Chelsea Public Schools
Everett City Hall
HarborCOV
The Home for Little Wanderers
Housing Families
Malden City Hall
North Suburban Consortium
ROCA
Other
3
Referring Partner's Name
First Name
Last Name
4
Referring Partner's Email Address
example@example.com
5
Do you have permission to submit this referral on the client's behalf?
YESNO
6
Would you like to be contacted before we reach out to this person?
YESNO
7
In this next section, please enter information as the client you are referring to CONNECT.
8
What is your name?* This field is required.
First Name
Last Name
9
What is your preferred language?* This field is required.Our staff primarily speaks English and Spanish, but we can support in just about any language.
Please Select
Please Select
English
Spanish
Haitian Creole
Portuguese
Arabic
Bosnian
Cambodian
Mandarin
Cantonese
French
Italian
Japanese
Khmer
Maay
Napali
Somali
Tagalag
Urdu
Vietnamese
Other
10
How can CONNECT help first?* This field is required.
Please Select
Please Select
I need emergency rent, mortgage, or utility assistance
I need help enrolling in benefits like SNAP
I need help finding work, or gaining skills for employment
I would like access to financial education, including classes and coaching
I would like to participate in CONNECT's free tax preparation services
I have medical debt, and I need support navigating my options
Please describe your most urgent need. We can discuss all opportunities when we speak.
11
What is your gender?
Female
Male
Non Gender Binary
Unknown
12
What is your email address
example@example.com
13
What is your cell phone number?* This field is required.
Please enter a valid phone number.
14
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NB*
*to NE in 1969
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
15
Do any of these housing situations apply to you?Please select all that apply
I have received a notice-to-quit document from my landlord
My landlord filed an eviction case against me in court
I have recently lost stable housing due to an unforeseen crisis (e.g. domestic violence, fire)
My utilities have been shut off, or are in danger of being shut-off
16
Briefly describe your housing situation?eg, "I fell behind on my rent and received an eviction notice"
Huge
Large
Normal
Small
Ok
Ok
17
Please describe your situationWhat financial assistance are you requesting and why do you need it?
Huge
Large
Normal
Small
Ok
Ok
18
I want to improve my credit and better understand how it works
YESNO
19
I need help organizing and understanding my finances
YESNO
20
I want to learn how to save money
YESNO
21
I want to prepare to buy a home
YESNO
22
I want to reduce my overall debt
YESNO
23
I want to learn about upcoming financial workshops
YESNO
24
I need help navigating medical debt
YESNO
25
Tell us about yourself* This field is required.What are your goals, and what would you like to accomplish in coaching sessions? Is there a specific question you would like to ask a coach? Feel free to share more information about your financial situation so our team can best help you.
Huge
Large
Normal
Small
Ok
Ok
26
Were you sent here by one of the following organizations?
Metro Housing Boston
Metro Credit Union
Bunker Hill Community College
MassHire
The Neighborhood Developers
27
CONNECT/The Neighborhood Developers seek to raise additional relief funds for other households in need. With your permission, CONNECT/The Neighborhood Developers will use your first name only and your story contained in this application for promotion, advertising, fundraising, and other purposes. Do we have your consent?* This field is required.
YESNO
28
Payment Information

If your application is approved, we will pay the company directly on your behalf. We need contact information so we can set a direct payment with the vendor. We are unable to send the funds to clients directly.
29
What do you need help with the most right now?
Please Select
Please Select
Education
Electricity
Gas
General Support
Internet
Oil
Phone
Rent
Technology
Training
Transportation
30
Payment AddressWhere payments should be sent
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
31
Are there any special instructions for handling the check?
Huge
Large
Normal
Small
Ok
Ok
32
Income Per Year* This field is required.What is your gross annual household income? Please estimate your TOTAL yearly income before taxes for all household members. (The total amount your family has available to pay for bills during the year)
Please Select
Please Select
$5,000 - $10,000
$10,000 - $15,000
$15,000 - $20,000
$20,000 - $25,000
$25,000 - $30,000
$30,000 - $35,000
$35,000 - $40,000
$40,000 - $45,000
$45,000 - $50,000
$50,000 - $55,000
$55,000 - $60,000
$60,000 - $65,000
$65,000 - $70,000
$70,000 - $75,000
$75,000 - $80,000
$80,000 - $85,000
$85,000 - $90,000
$90,000 - $95,000
$95,000 - $100,000
$100,000 or more
33
What is your date of birth?* This field is required.
Date
Year
Month
Day
34
Please select your race and ethnicity.* This field is required.
Please Select
Please Select
American Indian or Alaskan Native
Asian
Black/African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Other
Prefer not to answer
35
Are you of Hispanic, Latin, or Spanish Origin?* This field is required.
YESNO
36
Are you a US Military Veteran? or on Active Duty?* This field is required.
YESNO
37
Including yourself, how many people in your household are age 18+?* This field is required.
38
How many people in your household are age 0 - 6 years old?* This field is required.
39
How many people in your household are age 7 - 17 years old?* This field is required.
40
Including yourself, how many people in your household are 65+ years old?* This field is required.
41
Total Household Size* This field is required.
Should be Empty: