Apply for Advocacy

Full Name

Date of Birth

Phone Number

Email Address

Current Location (Address/Shelter/Area)

Preferred Contact Method Preferred Contact Method Phone Call Text Message Email

Veteran Status Veteran Status I am a veteran I am a family member of a veteran

Branch of Service

Years of Service (If Applicable)

Discharge Status (If Applicable)

Current Needs Current Needs Emergency Shelter Transitional Housing Permanent Housing Food Assistance Employment Support Mental Health Services Substance Use Recovery Legal Aid VA Benefit Support Transportation Family Support Services Other

Number of Adults in Household

Number of Children in Household

Are you currently staying with family or friends? Are you currently staying with family or friends? Yes No

Are you currently employed? Are you currently employed? Yes No

Place of Employment (If Applicable)

Do you have any other form of income? Do you have any other form of income? Yes No

Source of Income (If Applicable)

Do you have any documentation (ID, DD-214, etc.)? Do you have any documentation (ID, DD-214, etc.)? Yes No

Have you worked with another organization or case manager? Have you worked with another organization or case manager? Yes No

If yes, what organization?

Briefly describe your current situation or any urgent concerns:

I understand that the information provided will be used by CASS CARES solely for the purpose of providing advocacy, referrals, and support services. My information will not be shared without my consent unless required by law. I understand that the information provided will be used by CASS CARES solely for the purpose of providing advocacy, referrals, and support services. My information will not be shared without my consent unless required by law. Yes, I Consent