Community Intake Form
Share what you’re facing so we can connect you to the right support and resources.
Full Name
*
First Name
Last Name
Age Range
*
Please Select
15–17
18–24
25+
City
*
ZIP Code
*
County
*
What brought you here today?
*
Mental health concerns
Housing instability / homelessness
Financial hardship
Job loss / unemployment
Education / school issues
Family conflict
Loneliness / isolation
Need resources
Other
What do you need help with right now? (Check all that apply)
*
Mental health support
Housing / shelter support
Food assistance
Financial assistance
Job / employment help
Education support
Healthcare access
Legal assistance
Transportation help
Not sure
Do you need urgent help right now?
*
Yes – immediate crisis / unsafe situation
No – not urgent
Unsure
Are you interested in outside resources / program referrals?
*
Yes
No
Maybe
What type of resources do you need? (Check all that apply)
Housing programs
Mental health services
Financial assistance programs
Food assistance (SNAP, food banks)
Job placement programs
Healthcare services
Legal aid
Transportation services
Moderator / Community Support Interest
Would you be interested in helping support this community?
Yes
Maybe
Not at this time
Do you have experience with online communities or peer support?
Yes
No
Some experience
Agreement
Anything else we should know to better support you?
Submit
Should be Empty: