Direct Assist Intake Form | A Place to Rise

Please complete the form below to request assistance from A Place to Rise for yourself or for someone else. All information provided in the form is strictly confidential. If you need help completing this form, or if you have additional questions, please email us at admin@aplace2rise.org

STEP ONE: complete and submit the intake form below

STEP TWO: participate in a phone call with an intake committee member

STEP THREE: provide proof of residency or employment within the 10 towns we serve on the South Shore

Your Full Name

Your Email Address

Your Phone Number*

Town Serving

Best Way to Reach You:

Text

Phone

Referring Organization, Family, Friend, or Neighbor:

If you belong to a social service agency, work at a public school, or are affiliated with another nonprofit, please list the name below. Otherwise, please indicate your relationship as family, friend, coworker, etc. of the person for whom you are requesting assistance.

Affiliations, if any:

The questions below pertain to the individual and/or family in need of assistance:

If for someone else, what is their name?

Are they aware you are submitting this form?

Individual in Need's Phone Number:

Individual in Need's Email Address:

Please select which of the following South Shore towns you live in and/or work in: *Please note: we only serve the 10 towns listed and ask for proof of residency and/or employment therein.

Does the individual/family in need rent or own the home in which they currently reside?

How many adults (18+) live in the household?

How many children (if any) live in the household?

What are the ages of the children living in the household?

Are other organizations providing assistance? If so, please list them:

Please describe the current hardship that you and/or the person/family being nominated is facing. Please share as much information as possible to help us best assess our ability to meet those needs.

At A Place to Rise, we realize that, while our stories are similar, everyone faces unique challenges. How do you hope AP2R can help you/nominee, rise from these circumstances?

What other information, if anything, would be helpful for us to know?

Thank you for submitting the Intake Form. The intake committee will review your submission and get back to you as soon as possible.