Intake Form

Initial Application

Basic Information

Love INC is not an emergency service. We believe in taking time to hear your story and problem-solve with you. Part of the Love INC process is the verification of information shared. When contacted by Love INC, please be prepared to engage in the process.

Form submissions are sent over a SSL encrypted connection.

Date*

First Name*

Middle Name*

Last Name*

Date of Birth*

Phone Number*

To be able to assist you, we must be able to contact you by phone.

Message Phone

If your phone is not reliable or if you have a secondary number we can reach you at, please provide a message number. To be able to assist you, we must be able to contact you by phone.

Physical Address*

Where do you live? Please include street name, number, city, and zip code.

Have you ever contacted Love INC before?*

Yes

Referral

If you're a new client, how did you hear about Love INC?

Assistance Request

Please indicate what you are seeking assistance for. There are no guarantees Love INC will be able to assist with your request(s).

Financial Request

Car Repair

Home Repair

Mattress or Used Appliance Purchase

Water Bill

Other

Love INC's financial assistance is limited to $100 per year per household if approved. All financial requests require verification.

Almost Done!

The information provided in the following questions allows Love INC to better assist you with your request(s).

How do you get around?*

I get rides from family

I get rides from friends

I have a vehicle

I ride public transportation

Other

If approved, some Love INC assistance will require you to travel to an appointment within our Partner Church Network. If applicable, select more than one.

What is your housing situation?*

I am homeless

I own

I rent

I stay with someone

Please leave this field blank.

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