Family Intake Form

Please take a second and tell us a bit about you! We are excited to begin a relationship with you and your family. Our team will review the need and then get back with you as soon as we can! Praying for you.

Please fill out the person seeking help's information below:

Your name *

Email address *

Phone number *

Address *

If someone is helping you fill out this form, please let us know by giving us some info.

(Name, Agency, Phone Number, etc.)

Marital status

Names and age of children (under 18) living in the home? (Example: Dawn, 6) *

*Proof maybe required, based on request*

Names and age of adults (over 18) living in the home? (Example: Dawn, 25)

*Proof may be required based on request*

How can we help? Check ALL that apply. This will help us understand who will follow up. *

Childcare Interest at Refuge Kids (additional questions in this form)

Food Assistance

Spiritual Counseling (this is not therapeutic but peer to peer)

Financial Assistance

Other

What is your greatest need or concern? *

What is your current work status? *

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.