PCUL Client Assistance Pre-Screen Form 2026

CLIENT ASSISTANCE PROFILE FORM
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.
Email*
example@example.com
Would you like to sign up for news and resources?

YesNo
What type of assistance do you need today?*

Career/Workforce/Seniors Job ProgramStartup/Small BusinessHome WeatherizationLow Income Home Energy Assistance (LIHEAP)Living Emergency Assistance (Rental, Mortgage, Car, Other)Youth ProgramsParenting Programs
Are you still living in the same home you were in during the 2024 hurricane(s)?*

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

YesNo
If no, where are you currently staying?

With family/friendsTemporary shelterHotel/motelOther
Are you still dealing with hurricane damage? If so, what kinds of damage are you still dealing with today? (Check all that apply)*

Water damage inside the home (walls, floors, ceiling)Mold or musty smellsRoof damage or leaksBroken windows or doorsStructural issues (sagging floors, cracked walls, etc.)Electrical or plumbing problemsDamage to appliances or HVAC systemNoneOther (please describe)
Do you feel your home is safe to live in right now?*

YesNoNot sure
Have you received any help or repairs since the storm?*

Yes, from FEMAYes, from local organizationsYes, from family or friendsNo help yetOther (please explain)
Do you still need help with any of the following? (Check all that apply)*

Home repairsMold removalReplacing furniture or appliancesLegal help with insurance or landlordsEmotional/mental health supportFinding a safe place to liveNoneOther (please describe)
How prepared do you feel for the next hurricane season?*

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

Emergency kit (flashlights, batteries, water, food, etc.)Evacuation planGeneratorInsurance coverageNone of the above
Would you be interested in getting help or information on: (Check all that apply)

Emergency preparednessHome repair programsDisaster recovery resourcesHousing assistanceLegal or insurance supportMental health or counseling servicesVolunteer opportunities to help others
Please share your race/ethnicity (this information assists PCUL with funding applications and our census data)*

African American/Black/Afro-CaribAsian AmericanHispanic/LatinNative AmericanWhite/CaucasianOther
LIHEAP CLIENT ID (if applicable)
Is there anything else you’d like to share about your experience or needs?
Should be Empty:

CLIENT ASSISTANCE PROFILE FORM