Benevolence Forms

Benevolence Intake Form

Please fill out the form and submit it.

PERSONAL INFORMATION

* Indicates required field

Name *

First

Last

Age *

Gender *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Spouses Name *

First

Last

Children's Names & Ages *

Family Members Living with Person *

CHURCH & SUPPORT INFORMATION

Are you a member of Center? *

Yes No

If not a member, do you regularly attend Center? *

Yes No N/A

If not a member or attender, is this person connected to the church in any way? *

Has this person been previously assisted by the church? *

Yes No

If they've been assisted, when?

Month *

Day *

Year *

Reason for prior help: *

Has this person received help from other churches in the past year? *

Yes No

List the names & numbers of references to be contacted for further information regarding individual
(receive verbal permission to contact references)

Reference 1 *

First

Last

Phone Number *

Permission to Contact *

Reference 2 *

First

Last

Phone Number *

Permission to Contact *

Reference 3 *

First

Last

Phone Number *

Permission to Contact *

CURRENT SITUATION AND REASON FOR REQUEST

What is the current problem? *

Other important details: *

How long has this been going? *

Was this the result of abuse or exploitation? *

Has the individual contributed to the problem in any way? If so, how? *

What steps have been taken to fix the problem? *

What does the person think needs to be changed in the situation/themselves? *

What is the specific request of the church? *

Is the individual willing to work with the church to create an action plan to solve their problem? *

This form was started by: *

Month *

Day *

Year *

Submit

Benevolence Intake Form

Address

Telephone

Service Times