Community Assistance Intake Form

Community Assistance Intake Form

Help us understand your needs to provide support
Basic Information
Full Legal Name*

First NameLast Name
Preferred Name / Nickname
Date of Birth*

MonthDayYear
Date
Age*
Gender
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
PhoneTextEmail
Address Information
Street Address, City, State, ZIP Code, County*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Household Information
Number of People in Household*
Number of Adults*
Number of Children (under 18)*
Ages of Children
Food AssistanceYouth Program EnrollmentVeteran SupportMental Health / Healing ProgramsEmergency Financial HelpHousing ResourcesClothing / EssentialsSenior SupportOther
Funky U’s YouthKings MatterW.O.M.A.NSterling’s All-StarsV.E.T.E.R.A.NLet’s Heal TogetherKristi’s Pashen Unity FundGeneral Assistance
Veteran Status (If Applicable)
YesNo
Branch of Service
Years Served
Service-connected disability
Current Situation
Please describe the assistance you are requesting and your current situation.*
Immediate / EmergencyWithin a few daysWithin a weekGeneral support
Income Information (Optional)
Employment Status
Monthly Household Income Range
SNAPMedicaidSSI / SSDITANFNone
Referral Source
How did you hear about us?*
Birthday Program (Optional)
YesNo
Birthday

MonthDayYear
Date
Document Upload (Optional)
Upload Documents

Cancelof
Consent & Privacy Agreement
Electronic Signature
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

Community Assistance Intake Form

Basic Information

Address Information

Household Information

Veteran Status (If Applicable)

Current Situation

Income Information (Optional)

Referral Source

Birthday Program (Optional)

Document Upload (Optional)

Consent & Privacy Agreement

Electronic Signature