First Communication Bridge Outreach –
Client Intake Questionaire
Referral Information
Who referred you? (Name)
Referral Agent Code (if applicable)
Client Name / Household Name
Contact Details
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Working Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service Selection
Which service(s) are you requesting? (select all that apply)
*
Dominion Power Bill Discount/Credit
Columbia Gas Bill Discount/Credit
Both Dominion + Columbia Gas
Free Phone
Crisis resource connections
Internet access
Digital education
Youth workshops
Crisis resource connections
Other
Others: Please specify
*
Required Uploads ( Required For Utility Services Only)
Upload Screenshot of Current Dominion Power Bill
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Proof of Benefit eg Medicaid Card (Must be dated within the last 12 months)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Screenshot of Current Columbia Gas Bill
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Account Holder & Attendance Confirmation ( Required for Utility Services Only)
Is your name the same name listed on the bill?
Yes
No
Account Holder’s Full Name (as shown on the bill)
Relationship to Account Holder
Will the account holder be present for the appointment?
Yes
No (cannot schedule until confirmed)
Account Access Confirmation : To avoid delays during your appointment, please confirm the following: ( Required for Utility Services Only)
I can log in to my Dominion Power online account during the appointment
Yes
No
I can log in to my Columbia Gas online account during the appointment
Yes
No
I have access to the email address connected to the utility account(s)
Yes
No
Best email to use during appointment (if different from above):
example@example.com
Past-Due Balance Check - Required for Utility Services
Estimated past-due amount on the account (enter $ amount)
Acknowledgment checkbox:
I understand that if the past-due balance exceeds $300, it must be reduced to $300 or below before the credit/discount can be applied.
Appointment Readiness Checklist
Please bring and/or have ready at your appointment
Your phone (fully charged)
Ability to log in to your Dominion Power and/or Columbia Gas account
Access to the email connected to the utility account(s)
The account holder present (the person whose name is on the bill)
Have Medicaid Card / EBT and Proof of Benefits Paper
Notes
Additional Details
Friendly Professional Disclaimer
First Communication Bridge Outreach is a community outreach organization that works with authorized utility assistance programs through contracted processes. While we are not the utility provider, our role is to help eligible households complete the required steps to request available credits/discounts through the appropriate program channels.
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