Love In Action Intake Form

First name

Last name

Phone

Email

Family Information

How many people in your family?

How many adults?

How many children?

Are you married?

Yes

No

If not, how long have you been together?

Are you job hunting

Yes

No

I need assistance

Financial Information

To help us better understand your current needs, please answer the following questions about your income and financial support. All information is kept confidential and is used solely for intake and placement.

Are you empoyed?

Yes

No

Do you have medical issues keeping you from working?

Yes

No

If Yes Please Explain

Please upload a documented statement of your disability.

How Long will you be out of work?

Please explain other income sources.

Services Needed

What brings you to Love In Action for transitional housing assistance?

Can you share a bit about your current living situation and any challenges you are facing?

what other specific needs or services are you looking for in a transitional housing program?

Have you been part of any other housing or support programs before?

How can we best support you in achieving your goals for stability and independence?

Call us at 317-319-5564 once complete.