Crisis Assistance Screener 26-27
Please answer these questions to determine your eligibility for crisis assistance.
1. Does a member of the household have a diagnosed Intellectual or Developmental disability?
*
Yes
No
2. If someone in your home does have an Intellectual/Developmental Disability, do they work with Vaya Health for services?
*
Yes
No
3. Have you been in contact with other crisis agencies (Eblen, ABCCM, Catholic Charities, St. Vincent De Paul, Grace Covenant, DSS, etc)? We have to work with other agencies due to our limited funding.
*
Yes
No
3. Have you been served with an eviction notice or utility shut off date?
*
Yes
No
4. Is your need related to Hurricane Helene (displacement, housing, utility, loss of income, medical)?
*
Yes
No
If you were able to answer "yes" to questions please submit your information below and a representative will call you back to discuss our application process. You will need to have ready rental ledgers, utility "shut off" notices, and/or eviction paperwork, depending on your need.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: