Saint Vincent de Paul Intake Form

Saint Vincent de Paul Intake Form

St. Lawrence, Lawrenceville Conference
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Thank you for reaching out to the Lawrenceville Conference of the St. Vincent de Paul Society. Please carefully review the following important information before submitting your form:
- Completing this form does not guarantee services. Providing incomplete or false information may delay the review process and invalidate you from receiving services.
- Our ministry is staffed by volunteers. These individuals generously give their time to assist, so we appreciate your patience.
- Each case will be reviewed. If sufficient funds are available, an intake volunteer will contact you for any additional information needed.
- While not all cases can be assisted, all requests will be prayed for with care.
- Submitting multiple forms in the same month will not speed up the process.
- To protect confidentiality, all forms are cleared at the end of each month.
Thank you for understanding these guidelines as we strive to serve with compassion and fairness.
Please sign to acknowledge that you understand the above.*

Clear

Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Cell Phone (where you may be reached)*
Select your Gender.*
M- Male / F-Female
Email Address*
example@example.com
Using this key, please answer the following question regarding your race:
- A: Asian
- B/AA: Black/African-American
- C: White/Caucasian
- AI: Alaskan/Native American Indian
- H/L: Hispanic/Latino
- PI: Native Hawaiian/Pacific Islander
- O: Mixed/Other
- U: Undisclosed
What is your race?
What are the last 5 digits of your Social Security Number?*
In the last 12 months, have you been helped by a St. Vincent de Paul Conference (even if at a different location)?*

YesNoUnsure date
Please provide an approximate date when you were last helped.
Year(s)
What is your current Marital Status?*

SingleMarriedUnmarried CoupleDivorcedWidowerSeparatedDeserted/AbandonedUnknown
In order to best serve our neighbors in need, it is important for us to understand where you reside. The following questions will ask about your current residential address and living situation to help us provide appropriate assistance.
Which of the following best describes your current living situation?*

HomelessRoom/Boarding HouseHotel/ Motel/ Extended Stay/ ShelterLive in CarStaying with Friend/Family/otherType option 5Rent Apartment /Lot/SpaceType option 6Rent HomeOwn Home
If homeless, please select all that apply:

Currently living in carCurrently living on the streetAloneWith children
Street Address*
Last current address
City*
State*
Zip code*
We are only able to serve neighbors residing in the following zip codes: 30043, 30045, 30046, and 30019. This does not mean your case will not be considered, but another conference may be better suited to assist you based on your location.

If you live in the state of Georgia but outside these zip codes, we encourage you to call (678) 892-6163 for further assistance.
How long have you been living (staying) at this address?
St. Vincent de Paul does not discriminate on the basis of religion, faith, or any other characteristic. Our mission is to serve all individuals in need with compassion and dignity. However, as part of our process, we may ask if you are affiliated with a particular faith tradition to better understand your background and any resources that might be helpful to you. Your response is completely optional and will not affect our consideration of your request.
Are you parishioners of St. Lawrence?*

YesNo
What church do you belong to (if any)?
Additional Household Members
Total Number of Adults (18+) living in the home, including you?*
Total Number of Minor Children (under 18) living in the home?*
Does anyone in the household have a disability or special needs?*

YesNo
Total Number in Household
Employment Information

Our goal is to provide support that fosters lasting and meaningful change. In addition to addressing immediate needs, we may be able to connect or refer you with additional resources, such as employment support or assistance, to help build stability and reduce the risk of future challenges with housing or other necessities.
What is your current employment status?*
What type of assistance are you requesting? (Please select all that apply):*

Rent/MortgageElectricityWater / Sewer / TrashTelephoneTransportation/ CarPharmacy /MedicalClothing VoucherSNAP (Food Stamps)Other
For each category selected, please specify the amount of assistance needed (e.g., $200 for an overdue Georgia Power bill, including fees):*
If you wish, please upload a copy of any official document to help establish your identity. Additionally, include any document that verifies your current need, such as a utility bill or rental/lease agreement. This will ensure we have the necessary information to assist you effectively.

You will not be penalized for withholding this information until your case is accepted and you meet with a caseworker. All responses will be deleted weekly/monthly if they do not meet criteria for assistance or if assistance has been provided.
Cancelof
Are you receiving any of the following type of assistance?

SNAP (Food Stamps)Social Security and/OR SSI/SSDTANF (AFDC)NoneOther

What are your preferred days and time for a call back? (Please note our calendar ID may display as Restricted, Unknown Caller, No caller ID, or SVDP Helpline).

	Morning (9 a.m. - 11 a.m.)	Midday ( 11 a.m. - 2 p.m.)	Mid-afternoon (2 p.m. - 5 p.m.)	Evening ( 5 p.m. - 7 p.m.)
Monday
Tuesday
Wednesday
Thursday
Friday
Weekends (Sat & Sun)

Should be Empty:

Saint Vincent de Paul Intake Form

In order to best serve our neighbors in need, it is important for us to understand where you reside. The following questions will ask about your current residential address and living situation to help us provide appropriate assistance.

Additional Household Members

Employment Information