LeadHers Connect Community Resource Request
Need help finding community resources? Complete this short form to tell LeadHers Connect what you need. Do not provide Social Security numbers, banking/payment information, or other highly sensitive information. Submission does not guarantee funding, services, eligibility, placement, approval, or resource availability.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City
*
ZIP Code
*
Email Address
example@example.com
Preferred Contact Method
*
Text
Phone
Email
What type(s) of resources do you need? (Select all that apply)
*
Housing
Rent Assistance/Resources
Utility Assistance/Resources
Food
Clothing/Basic Needs
Employment
Transportation
Family Support
Youth Resources/Programs
Healthcare
Mental Health
Legal Assistance
Benefits/Community Services
Other
If you selected 'Other', please explain.
Please briefly tell us what you need help finding or accessing.
*
Is there a deadline or urgent date connected to this situation?
*
Yes
No
Urgent date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What will happen on or after this date?
Have you already contacted another organization or agency for help with this need?
*
Yes
No
Which organization or agency did you contact?
What was the outcome?
May LeadHers Connect follow up with you regarding this request?
*
Yes
No
Submit Request
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