SVDP at Christ the King Intake Form

Please select the zip code where you live:

If you do not reside in one of the zip codes listed, please call 678-892-6163 to be connected to the St Vincent de Paul volunteers nearest to you. Portions of zip codes 30318 and 30326 may be supported by another volunteer team, and if so, we will route your request accordingly.

Client Type*

New Client

Repeat Client

Date and Location of Last Visit*

Head of Household Information

Name*

First Middle Last

Social Security Number

Last 5 digits only

Date of Birth*

mm/dd/yyyy

Email Address*

Email Address

Gender*

Living Situation

Homeless

Hotel/Motel/Extended Stay

Room/Boarding House

Staying With Friend/Family/Other

Rent Apartment

Own Home

Address*

Street Address Address Line 2 City State ZIP Code

Hotel/Motel/Extended Stay Information

Hotel/Motel/Extended Stay Name Address City State ZIP Code

Apartment Complex Name

If applicable

How Long At This Address?

Primary Phone Number*

Are you currently employed?*

Yes

How long have you been employed?

How many people are in your household?*

How many children are in your household?*

Assistance Requested (select all that apply):

Food

Utility

Rent/Housing

Clothing Voucher

SNAP (Supplemental Nutrition Assistance Program)/Food Stamps

Medicaid

WIC (Special Supplemental Nutrition Program for Women, Infants, and Children)

Pharmacy

How much rent does your landlord say you owe?

How much do you have towards your rent?

Please tell us about your situation:

Please tell us a good day and time to contact you. We will do our best to contact you within the next couple of days. Our phone call may appear as “restricted”, “unknown caller”, “no caller ID”.

Authorization for Release of Confidential Information

In consideration of the services to be undertaken or rendered on my behalf by the Society of St. Vincent de Paul, its members, agents or affiliated organizations (hereinafter referred to as “SVdP”), I, the undersigned, hereby authorize SVdP to receive, from any and all sources, and to release to any person or organization, any confidential information regarding me which may be necessary or useful to SVdP in relation to the services to be rendered. I hereby release SVdP from all liability in any way related to the receipt and/or release of said confidential information. I further understand that the release of this information does not guarantee that assistance will be provided, but that without such information my case cannot be presented to the Conference/Council for consideration.

Please sign below*