2026 Crisis Center Intake Form
Today's Date
*
-
Month
-
Day
Year
Appointment Date:
Name
*
First Name
Middle Name
Last Name
Suffix
Address
*
Street Address
City
State
Zip Code
Phone Number
Please enter a valid phone number.
Sex
*
Please Select
Male
Female
Date of Birth (mm/dd/year)
*
Age
*
Marital Status
*
Please Select
Single
Married
Divorced
Separated
Email
example@example.com
How Many Living in Household?
*
Household Members: (Names & Ages)
County of Residence:
*
Race / Ethnicity:
Last 4 of SSN:
*
Are you Disabled?
Yes
No
Highest Education Completed:
Employer:
Income $:
Weekly or Monthly basis
Assistance currently receiving:
Medical Assistance
SSI/SSDI
WIC
Food Share
How did you learn about Foundations For Living (FFL)?
Reason For Seeking Assistance/ Types of Services Interested In:
Please verify that you are human
*
By signing this form, I agree that the information included in this form is true and accurate to the best of my knowledge. I hereby release Foundations For Living, Inc., Salvation Army, and each of their employees and/or volunteers, from any liability resulting from the exchange of confidential client information only relating to this request for service. This authorization will remain in effect for one (1) year from the date signed. I may withdraw this statement at any time with written notice. The confidentiality of shared information is protected under state and/or federal law.
*
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