Welcome! This form helps us understand your current situation so we can connect you with the right support. There are no right or wrong answers — please share only what you feel comfortable with. It should take about 10 minutes to complete.
Section 1 — Personal Identification
What's your full legal name?
What name do you prefer to go by?
Is there a safe way for us to contact you? Please describe any preferences (e.g. text only, avoid calling before 9am):
Section 2 — Housing Situation
Where are you currently staying? Select all that apply:
Is your current housing situation stable?
Is there anything more you would like to share about your housing situation?
Section 3 — Food Security
How would you describe your current access to food? Select all that apply:
Please describe any dietary needs or restrictions we should know about:
Section 4 — Health and Medical Needs
You only need to share what you feel comfortable with. This helps us connect you with appropriate health support.
Do you currently have a doctor or primary health care provider?
Are there any current health needs or concerns we should be aware of? (e.g. medication access, mobility, mental health support):
Do you currently have health insurance or a benefits card?
Section 5 — Employment and Income
What best describes your current employment status? Select all that apply:
What are your current sources of income? Select all that apply:
Is there anything else about your employment or income situation you would like to share?
Section 6 — Support Network
Understanding who is already in your corner helps us build on your existing strengths.
Who do you currently have in your support network? Select all that apply:
Is there a person we can contact on your behalf in case of an emergency? If yes, please share their name and phone number:
Is there anything else about your support network you would like to tell us?
If you have any documents that may help us understand your situation better (e.g. ID, medical letters, benefit statements), you are welcome to upload them here. This is optional.
Thank you for taking the time to fill this out. Your information is kept confidential and will only be used to connect you with the support you need. A member of our team will be in touch with you shortly.