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Advocacy Intake Form
Please complete this form as honestly and completely as possible. All information that you provide is secure and confidential as required by state and federal law.
Feel free to upload any documents you feel are essential to understanding your situation and circumstance.
You will be contacted within 24 business hours, usually the same day.
Personal Information
First Name
Last Name
Street Address
City
Street Address Line 2
State
Postal / Zip code
Contact Information
Email
Cellphone
Home Phone
Other Contact Info
Preferred Contact Time: Select One
*
Morning
Afternoon
Evening
Any Time
Preferred Contact Method: Select One
*
Home Phone
Cellphone
Email
Text Message
Additional Information about Contacting You (optional)
Additional Information
Are you a Crowd Proud client?
Choose an option
Are you a Veteran?
Choose an option
Select the MAIN reason for the nature of your request?
Children & Youth Services (CPS)
Probation
Parole
Utility Shut-Off Notice
Utilites Shut Off
Other (please explain below)
If CPS, what county?
Please provide a brief summary of the reason(s) for your request.
This Intake Form is part of Crowd Proud's mission to Advocate and Support
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