Emergency Assistance Intake Form

Emergency Assistance Intake Form

Emergency Assistance Intake Form

Wise Protective Services & More, Inc.
Applicant Information
Full Legal Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Phone Number:*
Email Address:
Preferred Method of Contact:*

PhoneTextEmail

Emergency Assistance Intake Form

Wise Protective Services & More, Inc.
Safe Contact Information
Is it safe for us to contact you using the information provided?*

YesNo
Please tell us when and how it is safe to contact you.*

Emergency Assistance Intake Form

Wise Protective Services & More, Inc.
Household Information
Number of adults in household:*
Number of children in household*

Emergency Assistance Intake Form

Wise Protective Services & More, Inc.
Current Situation
Please briefly describe your current emergency and why you are requesting assistance:*

0/100
Are you currently experiencing or recovering from a crisis?

Domestic violenceHousing instabilityMedical emergencyJob lossOtherPrefer not to say
Other:*

Emergency Assistance Intake Form

Wise Protective Services & More, Inc.
Financial Snapshot
Approximate monthly household income:*
Are you currently receiving any government assistance?*

YesNo
Type of government assistance:
Other:*

Emergency Assistance Intake Form

Wise Protective Services & More, Inc.
Partner Support / Prior Assistance
Are you currently working with a support organization or community partner?*

YesNo
Organization name:*
Staff Contact:
Have you received emergency assistance from WPSM before?*

YesNo
Approximate date of assistance:*

Emergency Assistance Intake Form

Wise Protective Services & More, Inc.
Important Notice
Documentation may be requested if needed to verify emergency assistance requests. Submission of documents is not required to apply.

Emergency Assistance Intake Form

Wise Protective Services & More, Inc.
Consent & Confidentiality
Consent:*

I consent to Wise Protective Services & More, Inc. collecting and using my information solely to evaluate and provide emergency assistance.
Optional Consents:

I consent to the use of anonymized information for nonprofit reporting.I consent to the use of photos or stories for nonprofit communications.

Emergency Assistance Intake Form

Wise Protective Services & More, Inc.
Certification & Signature
Certification:*

I certify that the information provided is true and accurate to the best of my knowledge.
Signature:*

Clear
Date:*

MonthDayYear
Priority Level:
Review Status:
Notes:
Should be Empty: