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Support Request Form
GRACE provides programs and support services to individuals and families in northeast Tarrant County. If you reside in our service area, you will be prompted for your information. After submission, a Care Manager will be in touch to schedule an appointment.
Residency Requirement
Please provide your city of residence to confirm you're within our service area.
City
*
Please Select
Bedford
Colleyville
Euless
Flower Mound
Fort Worth
Grapevine
Haltom City
Hurst
Keller
Lewisville
North Richland Hills
Richland Hills
Roanoke
Southlake
Trophy Club
Watauga
Westlake
None of the Above
City of current residence
Zip Code
Please Select
75022
75028
75067
76040
76137
76177
76244
None of the Above
City of current residence
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Next
We're Sorry, but you live outside our service area.
According to the information you entered, you do not qualify for assistance. Contact 2-1-1 or visit Texas Health & Human Services for assistance that might be available.
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You meet our service area requirement!
Complete the information below and a Care Manager will contact you to schedule an appointment.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
First Name
*
Last Name
*
Email
*
Phone Number
*
Format: (000) 000-0000.
Home Address
*
Street
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Are you 65 or older?
*
Yes
No
School District Zip Code
*
School District
*
Birdville
Fort Worth
Lewisville
Carroll
Grapevine-Colleyville
Keller
Coppell
H-E-B
Other
Services Requested (check all that apply)
*
Food Pantry
Community Clinic
Mentorship Housing
Senior Services
Back to School Supplies (Summer only)
Christmas Cottage (Winter only)
Rental Assistance
Utility Assistance
Other Financial Assistance
What utility provider(s) do you need assistance with? (check all that apply)
Ambit
Atmos
Reliant
TXU
Other
Do you have a disconnection notice scheduled in the next 24 to 48 hours?
Yes
No
Submit
Should be Empty: