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SVDP at Our Lady of the Mountains Intake Form

To request financial assistance, please fill out the form below, starting with the drop-down box regarding your county of residence.

"*" indicates required fields

Please select the county where you live:

If you do not reside in Pickens County, you will not be eligible for assistance through the Our Lady of the Mountains 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 Conference that may be able to assist you.

Head of Household Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email Address

Date of Birth*

MM slash DD slash YYYY

SSN (last 5 digits)

Living Situation

Own Home (with or without mortgage)

Rent

Homeless

Hotel/Motel/Extended Stay

Room/Boarding House

Staying With Friend/Family/Other

Hotel/Motel/Extended Stay Information

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

Apartment Complex Name

If applicable

How many adults are in your household (18-59)?*

How many children are in your household (0-17)?*

How many seniors are in your household (60+)?*

Are you employed?

Yes

No

Assistance Requested (select all that apply):

Food

Utilities

Rent/Housing

SNAP (Supplemental Nutrition Assistance Program)/Food Stamps

TANF (Temporary Assistance to Needy Families)

CAPS (Childcare and Parent Services)

Medicaid

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

Clothing

Prescriptions

Other

What assistance are you requesting?*

Please tell us about why you need assistance:

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URL

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First Name*

Last Name*

Email*

Zip Code*

Areas of Interest

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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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