Thank you for reaching out. We know this is a tough time for you, but we are here to help. Please complete the form below.
Name
Age
Phone number
Email
Where did you sleep last night? ShelterHotel/MotelFriend or family's homeParkCarWoods or encampmentUnder a bridgeOther
How long have you been homeless? Less than one month1-3 months4-6 months6 months or more
I mainly need help with: Emergency shelterSomething else
I also need help with: (select all the apply) Educational attainment (get my GED, etc.)Finding a jobFoodIdentification (getting birth cert, ID card, etc.)ClothingMedical/Mental issue
Do you have children? YesNo
How many adults are in your household? (18 years or older)
Are you a Veteran? YesNo
Are you Disabled? YesNo
What county are you seeking to receive services? —Please choose an option—CamdenFranklinGlynnMcIntoshWayne
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