Social Services Appointment Request Form
The Salvation Army, an international movement, is an evangelical part of the universal Christian Church. Its message is based on the Bible. Its ministry is motivated by the love of God. Its mission is to preach the gospel of Jesus Christ and to meet human needs in His name without discrimination.
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requested Appointment to Discuss Which Service(s)
You may select more than one service. Selecting multiple services does not increase speed of service or reply. Requests are responded to on a first come, first served basis.
Services
Housing Navigation
Enhanced Care Management
Medically Tailored Groceries or Meals
Emergency Utility Assistance (15 Day or 3 Day Pay or Quit Required)
Emergency Rental Assistance (3 Day Pay or Quit Required)
Pastoral Care Call
Children & Teen Programming Information
Other
Are service(s) selected related to benefits available through Partnership Health Plan of California?
Yes
No
Insurance Provider
Insurance ID (CIN) #
Please express your reason for requesting the service(s)
Do you have a notice from your utility provider?
*
Yes, a 15 Day Notice
Yes, a 3 Day Pay or Quit
No
How much do you owe on your bill?
*
Are you on a repayment plan?
*
Yes
No
Please share what kind of one-time hardship you have experienced that cause you to fall behind on your bill
*
Please share a the full story of what happened.
Do you have a notice from your Landlord?
*
Yes, a 3 Day Pay or Quit
No, not yet
How much to you owe on your rent?
*
Have you spoken with your landlord to negotiate a payment plan?
*
Yes
No
Please share what kind of one-time hardship you have experienced that cause you to fall behind on your rent
*
Please share a the full story of what happened.
Submit
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