CUE's Public Health and Safety Department Programs Intake Form
We help Vallejo residents reduce stress, stay safe, and move forward through healing support, counseling, case management, and short-term financial help.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Second Phone Number (Friend or Relative)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Gender Identification
Please Select
Male
Female
Transgender
Gender Neutral
Non-binary
Gender Queer
Not willing to disclose
Race
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you currently unemployed?
*
Yes
No
Where do you work?
*
What is your education status?
*
Please Select
Below High School
High School Grad
Associates Degree
Bachelor's Degree
Beyond Bachelor's Degree
Name of School Currently Attending (if it does not apply please but "N/A")
*
Are you involved in any other programs?
*
Are you a current or former foster youth?
*
Yes
No
Do you have a valid California Drivers License?
*
Yes
No
Are you a single individual who has primary responsibility for one or more dependent children under the age of 18?
*
Yes
No
Are you currently homeless or living doubled-up?
*
Yes
No
Neighborhood Affiliation
*
Are you concerned with your safety?
*
Yes
No
Are you a victim/survivor of gun violence or feel the need to carry a weapon?
*
Yes
No
Do you identify as a person with a mental health or substance use challenge?
*
Yes
No
Who referred you to L.O.V.E.? ( The person or organization name and phone number or email)
*
Do you participate in any of these programs?
*
Criminal Justice-Involved (at any point, past or present)
Free and Reduced-Price Lunch (NSLP) and/or School Breakfast (SBP) programs
Home Investment Partnerships Program (HOME), for affordable housing programs
Medicare Part D Low-income Subsidies-Supplemental Security Income (SSI)
Medicaid-National Housing Trust Fund (HTF), for affordable housing programs
Supplemental Nutrition Assistance Program (SNAP)
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) - Section 8 Vouchers
Temporary Assistance for Needy Families (TANF)
N/A
Please select top 5 you need immediate support with:
*
Benefits Eligibility Screening
Career Skills Development
Clothing
Diapers/Infant Supplies
Educational Support Services
Enroll in Therapy*
Emergency Food
Enroll in Drug Treatment Program*
Financial Literacy Classes
Housing/Rental Assistance*
ID/Documentation Assistance
Job Search/Placement
Mental Wellness Expense Assistance
Mental Wellness Information/Education
Relocation Support
School Supplies
Tax Preparation Services
Transportation Expense Assistance
Toiletries/Personal Hygiene Products
Tuition Assistance
Transportation Passes/Vouchers
Utility Bill Payment Assistance
Other
Submit
Should be Empty: