Client Intake Form | Trident United Way

Trident United Way is here to help connect you to resources and support. Please complete this form to the best of your ability. Your responses are confidential and will only be used to match you with the right services. Our Intake Specialists will contact you to guide you through the next steps.

First Name

Last Name

Date of Birth

What ZIP code do you live in?

Please provide your county of residence

Please provide your email (if no email address, please type "N/A"):

Please provide your phone number:

How would you like to be contacted?

Please select what time of day you prefer to be contacted. (Select all that apply)

Morning

Afternoon

Evening

How were you referred to this program? (Select one)

Please provide the name of the organization/agency that referred you.

Do you have any school-aged children living at home?

Please select the option that best describes your military affiliation.

What is your current employment status? (Select one)

Who is your current employer(s)?

	How can we help you today? (Choose all that apply)
Housing (rental assistance, utilities, housing repairs, mortgage assistance, eviction, shelter, homelessness)	Housing (rental assistance, utilities, housing repairs, mortgage assistance, eviction, shelter, homelessness)
Transportation (car payment and insurance, car repairs, bus tickets, driver's education, gas, ride-sharing)	Transportation (car payment and insurance, car repairs, bus tickets, driver's education, gas, ride-sharing)
Food (food pantries, baby food, application assistance for SNAP and/or WIC, nutritional assistance)	Food (food pantries, baby food, application assistance for SNAP and/or WIC, nutritional assistance)
Health (medical and prescription bills, dental appointments, free clinics, urgent care, health screenings, counseling and mental health services, substance abuse treatment)	Health (medical and prescription bills, dental appointments, free clinics, urgent care, health screenings, counseling and mental health services, substance abuse treatment)
Child Care (child care subsidies, after school programs, school supplies, developmental screenings)	Child Care (child care subsidies, after school programs, school supplies, developmental screenings)
Employment and Education (job training, unemployment services, GED and other adult education, job search, college and trade schools, English as a Second Language)	Employment and Education (job training, unemployment services, GED and other adult education, job search, college and trade schools, English as a Second Language)
Legal Aid (immigration legal assistance, eviction prevention, elder law, family law, discrimination legal assistance, heirs property)	Legal Aid (immigration legal assistance, eviction prevention, elder law, family law, discrimination legal assistance, heirs property)
Financial Literacy (budgeting courses, debt reduction, asset building, banking assistance)	Financial Literacy (budgeting courses, debt reduction, asset building, banking assistance)
Hygiene (clothing, diapers, shower)	Hygiene (clothing, diapers, shower)
Disaster (disaster relief, disaster recovery, disaster shelter, disaster preparedness)	Disaster (disaster relief, disaster recovery, disaster shelter, disaster preparedness)

Please describe:

Please provide any details on how we can best support you.