Community Intake Form

Community Intake Form

Share what you’re facing so we can connect you to the right support and resources.
Full Name

First NameLast Name
Age Range
City
ZIP Code
County
What brought you here today?

Other
What types of resources, navigation, or referrals are you seeking? (Check all that apply)
Do you need urgent help right now?
She Is Us United Inc. is not an emergency response, crisis intervention, or emergency shelter provider. This form is not monitored for emergencies. If you are experiencing an immediate emergency, call 911. For community and social-service resources, call 211. For suicide, mental health, or emotional crisis support, call or text 988.
Are you interested in outside resources / program referrals?
What type of resources do you need? (Check all that apply)
Moderator / Community Support Interest
Would you be interested in helping support this community?
Do you have experience with online communities or peer support?
Agreement
I understand that She Is Us United Inc. is not an emergency response service, emergency shelter, crisis intervention provider, financial assistance provider, healthcare provider, or legal services provider. I understand that the organization primarily provides peer support, education, resource navigation, and referrals, and that submitting this form does not guarantee services, funding, housing, employment, placement, or other assistance.
Anything else we should know to better support you?
Should be Empty: