Client Intake Form

Client Intake Form

Client Intake Form

Welcome!
Please take a few minutes to fill out this form so we can try our best to match you with the support that meets your needs.

* By submitting this form and providing us with your contact information, you consent to us contacting you to support your request.

Intake Type
Referral Source
Referring Partner's Name

First NameLast Name
Referring Partner's Email Address
example@example.com
YesNo
YesNo
Is there any additional context that is helpful for the CONNECT team to know?

In this next stection, please enter the information as the client you are referring to CONNECT.

About you:
What is your name?*

First NameLast Name
What is your preferred language?*
WomanManNon gender binaryUnknown
Mobile Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com

Hi, {whatIs}
How can CONNECT help first?*
What is your mailing address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I am not behind on rent, but I am behind on at least one utility billI received a Notice to Quit document from my landlordMy landlord has filed an eviction against me in courtI have lost my housing due to an unforeseen event (e.g. fire or flood)My Doctor told me I need to move for health reasonsI am the victim of domestic violence and I am not currently safeNone of the above
Briefly describe your need for utility or rent assistance*

Tell us about your situation*

File Upload

Cancelof

Tell us about your situation*

YesNo
Tell us about your situation

Record Type ID
Language (Hidden)