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SVDP at Christ the King Intake Form

Please fill out the form below to submit your request for financial assistance. A volunteer caseworker will contact you via telephone or email. Thank you.

"*" indicates required fields

Please select the zip code where you live:

If you do not reside in one of the zip codes listed, you will not be eligible for assistance through the Christ the King St. Vincent de Paul Conference. Please call the main St. Vincent de Paul Georgia assistance line at 678-892-6163 to be connected with a local Conference that may be able to assist you. You may also visit our Client Resource Center for Job Opportunities and Other Resources at www.svdpgeorgia.org/crc.

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

MM slash DD slash 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

No

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”.

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Phone

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First Name*

Last Name*

Email*

Zip Code*

Areas of Interest

Neighbor Resources

Volunteer Opportunities

Vincentian News & Updates

Donor and Impact News & Updates

Mission

To serve our neighbors with love and respect: delivering help, hope, and pathways to self-sufficiency.

Location & Hours

2050-C Chamblee Tucker Road
Atlanta, GA 30341

Monday - Friday:
8:30 AM – 4:00 PM

Contact

Main: (678) 892-6160

Assistance: (678) 892-6163

Pharmacy: (770) 687-2610

info@svdpgeorgia.org

Donations: gifts@svdpgeorgia.org

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