[[trackingImage]]

UNI Cares Project - Service Intake Form

All information is kept confidential and used solely for service provisions or referrals.

Section 1: Personal Information
* Full Name:
0/50
* Date of Birth:
0/50
* Gender Identity:
* Race/Ethnicity:
* Phone Number:
0/50
* Email Address:
0/50
* Current Living Situation
Do you have dependents (Children or others you care for)?

Section 2: Military & Veterans Status
* Have you served in the U.S Military?
If yes, what branch did you serve in?
What was your discharge status?
Do you have a VA ID Card or Access to VA services?
Are you currently receiving any Veteran Benefits?
Would you like assistance connecting to Veteran Services?

Section 3: Services Requested

Please check all the services you are requesting, If we are unable to provide a service, we may refer you to a trusted community partner.

* Food & Nutrition Assistance
* Housing Assistance
Financial Assistance
Employment & Workforce Development
Healthcare & Wellness
Harm Reduction & Outreach Services
Veterans Assistance
Youth & Family Services
Legal & Identification Services

Section 4: Employment & Financial Status
* Are you currently employed?
* Are you receiving any government assistance? (Check all that apply)
Do you have a bank account?
* Are you currently struggling with Debt or credit issues?

Section 5: Health & Safety
Do you have any medical conditions or disabilities that require special assistance?
Do you have any mental health concerns you need assistance with?
Are you currently struggling with Substance use?
Have you experienced Domestic Violence or Trafficking?

Section 6: Emergency Contact Information
* Emergency Contact Name:
0/50
* Relationship to You:
0/50
* Phone Number:
0/50

Section 7: Additional Information & Referral Source
* How did you hear about UNI Cares Project?
Is there anything else you would like us to know?
0/250

Consent & Acknowledgment

I acknowledge that the information provided above is accurate to the best of my knowledge. I understand that UNI Cares Project will use this information to determine my eligibility for services and that my information will remain confidential. I understand that if a requested service is not available through UNI Cares Project, I may be referred to a community partner for assistance.
* Signature:
0/50
* Date:
0/50
Submit Survey

UNI Cares Project | 2375 E Tropicana Ave Suite 8 PMB 153 | Las Vegas, NV 89119 US

Constant Contact Data Notice

Constant Contact