Fresh Start Intake Form
Section 1: Applicant Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact
*
Phone Call
Text Message
Email
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this your current address?
Yes
No
Section 2: Household Information
How many people live in your household? (Number)
*
How many adults (18+)
blank
*
Children (17 and under)
blank
Seniors (65+)
blank
Are there any infants, elderly individuals, or individuals with disabilities in the home?
*
Yes
No
If yes, please explain (optional)
This information is used to better understand the need of the household and to properly assist.
Do you currently receive any assistance programs?
SNAP/Food Assistance
TANF
Medicaid
Housing Assistance
None
Other
Section 3: Cleaning Assistance Request
Only fill this section if you are requesting FREE cleaning services. If not requesting a cleaning, skip to section 4.
What type of cleaning assistance are you requesting? (Check all that apply)
General Home Cleaning
Kitchen Only Cleaning
Bathroom Only Cleaning
Bedroom Only Cleaning
Laundry Assistance
Light Cleaning (Dusting, Sweeping, Mopping, etc)
Other
If other selected, please explain.
How many bedrooms are in the home?
How many bathrooms are in the home?
Approximate size of the home:
Apartment
Small Home
Medium Home
Large Home
Unsure
What areas of the home need the most attention?
How long has it been since the home received a deep cleaning?
Less than 1 month
1-3 months
3-6 months
6+ months
Prefer not to answer
Are there any conditions that we should be aware of before arriving? (Check all that apply)
Pets in the home
Heavy clutter
Large amounts of trash
Mold/Water damage
Strong odors
Pest concerns
Other
If other selected, please explain:
Photo Upload
Please upload photos of the areas needing assistance. (Photos help us prepare the correct supplies and estimate the amount of support needed.)
Upload: Kitchen, Bathroom(s), Bedroom(s), Main living areas.
Browse Files
Drag and drop files here
Choose a file
Cancel
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Section 4: Meal Assistance Request
Would you like to request meal assistance?
Yes
No
Does anyone in your household have dietary restrictions or allergies?
None
Vegetarian
Vegan
Gluten-Free
Dairy-Free
Nut Allergy
Diabetes -Friendly
Low Sodium
Other
Please list other dietary restrictions or food allergies below:
Are there any foods your household does not eat?
Are there any foods that your family prefers?
Section 5: Scheduling
What days work best for assistance?
Preferred Day:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Time:
*
Morning
Afternoon
Evening
Section 6: Additional Information
Please briefly why you are requesting Fresh Start assistance:
*
How did you hear about Fresh Start?
*
Church
Community partner
Social Media
Friend/Family
Other
How soon do you need assistance?
*
ASAP (within 1-2 weeks)
Within 30 days
No specific timeline
Is there anything you would like us to know about you and/or your family?
Agreement Section
*
I understand Fresh Start services are provided at no cost through The Village Project and availability is based on volunteer capacity and resources.
*
I give permission for The Village Project volunteers to enter my home for approved services
*
I understand photos submitted will only be used to prepare for service planning and will remain confidential.
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Should be Empty: