PCUL Client Assistance Pre-Screen Form 2026

Pinellas County Urban League offers programs that support individuals and families in achieving economic stability and overall well-being, including workforce and career support, home energy assistance, health and wellness resources, and youth development programs.

To help us connect you with the most appropriate services, all prospective participants are asked to complete a brief screening process to assess needs, eligibility, and goals. Completion of the screening does not guarantee enrollment, but it is an important first step in identifying available resources; all information provided will remain confidential and will be used solely to determine program fit and next steps.

A staff member will be in touch with you within 48-72 hours. Please check your email for the next steps. We look forward to connecting with you soon.

For emergency assistance, contact 211 for free and confidential crisis and emergency counseling, disaster assistance, food, health care and insurance assistance, stable housing and utilities payment assistance, employment services, veterans' services, and childcare and family services. Calling is available 24 hours a day, 7 days a week. 

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Would you like to sign up for news and resources?

What type of assistance do you need today?

Are you still living in the same home you were in during the 2024 hurricane(s)?

If no, where are you currently staying?

Other

Are you still dealing with hurricane damage? If so, what kinds of damage are you still dealing with today? (Check all that apply)

Do you feel your home is safe to live in right now?

Have you received any help or repairs since the storm?

Do you still need help with any of the following? (Check all that apply)

How prepared do you feel for the next hurricane season?

Do you currently have any of the following in case of a future storm? (Check all that apply)

Would you be interested in getting help or information on: (Check all that apply)

Please share your race/ethnicity (this information assists PCUL with funding applications and our census data)

LIHEAP CLIENT ID (if applicable)

Is there anything else you’d like to share about your experience or needs?

CLIENT ASSISTANCE PROFILE FORM