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Old Books

HELLO THERE! Let’s Get You Started.


To help us better understand your needs and connect you with the appropriate support, please complete the S.O.S. Intake Form. All questions marked with an (*) are required.
 

Once your intake form is received, a member of our team will review the information submitted and follow up with you regarding appropriate next steps, resources, and available support.

SistaH of SurvivaL Intake Form

Multi-line address
Birthday
DĆ­a
Mes
AƱo
Best way to contact you? (Please check all that apply & enter below):
What Do You Need Right Now?
What are your most urgent needs? (Select all that apply)
Household & Health Insurance Information
Do you currently have Medicaid (Medical Assistance) health insurance?
Yes
No
I'm Not Sure
Do you currently have any children under the age of 18 living with you or in your care?
Yes
No
If yes, how many children are currently in your care?
Safety Check
Do you feel safe in your current environment?
Yes
No
Unsure
Would you like someone from our team to contact you within 24-48 hours?
Yes
No
Interest & Intent
Based on your age group, select the program that applies to you.
Consent
Do you agree to be contacted regarding resources and support services?
Yes
No
Participant Age & Program Consent Acknowledgment
I confirm that I am 18 years of age or older and understand that I may participate in eligible SistaH of SurvivaL programs as an adult participant.
I confirm that I am under 18 years of age and understand that parent or legal guardian consent may be required before I can participate in any SistaH of SurvivaL program.

Participants under 18 may need parent or legal guardian consent before program participation begins. SistaH of SurvivaL may request additional consent documentation. Submission of this intake form does not guarantee enrollment or approval.

Single SistaH of SurvivaL (S.O.S.) works to connect participants with community resources and independent service providers based on their individual needs. How would you prefer to receive external referral assistance?
Resource Information Only: I prefer to receive information about available community resources and contact providers independently.
Referral Coordination Assistance: I would like S.O.S. to assist me in connecting with appropriate external providers. I understand that additional authorization may be required before my personal information is shared.
No External Referrals at This Time: I do not wish to receive external referral assistance at this time.

Participation in S.O.S. programs are not dependent upon selecting a particular referral option. External referrals do not guarantee eligibility, acceptance, housing, or other services.

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