TCRA Intake Form

TCRA Intake Form
Survivor Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Alternate Contact

First NameLast Name
Alternate Contact Phone
Please enter a valid phone number.
Alternate Contact Email
example@example.com
Disaster
Select the disaster you were affected by
Affected Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Survivor Needs

Debris RemovalDriveway RepairFencingHome RebuildHome RepairsMuck-outMold RemediationRoofingOther
Survivor story:
Please give details about your experience and your specific needs.
RELEASE OF INFORMATION

I authorize Travis County Recovery Alliance (TCRA) to share relevant information about my situation, needs, and recovery progress with trusted partner organizations and agencies participating in disaster recovery efforts. The purpose of this release is to allow TCRA and its partners to coordinate services, provide assistance, and support my long-term recovery needs. This may include—but is not limited to—information related to property damage and rebuilding needs, financial or material assistance requests, or case management and referral updates.

I understand that my information will only be shared with verified disaster relief and recovery partners working toward community recovery and I may revoke this authorization at any time by providing written notice to TCRA.

TCRA and its partners agree to keep my information confidential and use it solely for disaster recovery purposes.
Signature*

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