Unmet Needs Intake Form

Unmet Needs Intake Form

Calumet, Outagamie, Winnebago Long-Term Recovery Committee
For disaster-related needs not fully addressed through insurance, government programs, or available community resources
Important: This form is a request for review and referral. Submission does not guarantee financial assistance, services, eligibility, or approval. This form is not for business owners. Do not attach Social Security numbers, full bank account numbers, medical records, or other highly sensitive records unless specifically requested through an approved secure process. If there is an immediate threat to life or safety, call 911.
A. Intake and Incident Information
Date received:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Intake source:
Incident / disaster name:
Incident date(s):

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
B. Applicant / Household Information
Applicant / household name:

First NameLast Name
Preferred name:

First NameLast Name
Primary phone:
Format: (000) 000-0000.
Email:
example@example.com
Current mailing address:

Street Address

Street Address Line 2

CityState

Zip Code
Damaged property address, if different:

Street Address

Street Address Line 2

CityState

Zip Code
Preferred contact method:
Best time to contact
C. Household Information
Adults in household:
Children in household:
Pets / service animals:
Are you a:
Are you currently displaced?
Language preference:
D. Disaster Damage Details
Select all the damages, bills, or costs that are currently impacting you due to the disaster. Use the notes area to identify the location, severity, and immediate concern.
Damages caused by the disaster and are still unmet needs:
Property damage items
Bills or ongoing expenses affected because of the disaster:
Temporary household costs caused by the disaster:
Damage and expense notes:
E. Impact of the Damage
Select all current impacts or unmet needs.
Current Employment impact due to disaster:
Describe how employment or household income has been affected due to disaster:
Other current impact(s):
Other impact or unmet needs not already listed:
F. Assistance Already Requested or Received

F. Assistance Already Requested or Received (People of Progression, Red Cross, LEAVEN, etc.) If you have not received assistance, put NA.

Rows	Organization	Date Contacted	Status / Assistance Received
1
2
3
4

Insurance status:
G. Consent to Coordinated Services
I confirm that the information provided is accurate to the best of my knowledge. I authorize participating disaster-recovery partners to use and share the minimum information necessary to review this request, coordinate referrals, avoid duplication of benefits, and follow up on outcomes. I understand that I may withdraw this authorization in writing, subject to information already used or disclosed. Do not attach Social Security numbers, full bank account numbers, medical records, or other highly sensitive records unless specifically requested through an approved secure process.
Consent Option
Printed name:

First NameLast Name
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to applicant, if applicable:
Staff / intake worker:

First NameLast Name
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant / authorized representative signature:
Should be Empty:

Unmet Needs Intake Form

A. Intake and Incident Information

B. Applicant / Household Information

C. Household Information

D. Disaster Damage Details

E. Impact of the Damage

F. Assistance Already Requested or Received

G. Consent to Coordinated Services