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

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 pertaint 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:

Individual in Need's Physical Address:

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 individual's current need and/or hardship. Please share as much information as possible to help us best assess our ability to meet those needs.

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