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Submitting this form does not guarantee financial assistance or services. Assistance depends on eligibility, available resources, funding, program capacity, and the nature of the request.

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Section 1 - Applicant Information

Full Name: _______________________________________________________

Preferred Name: _______________________________________________________

Phone Number: _______________________________________________________

Email Address: _______________________________________________________

Preferred Method of Contact:

☐ Phone

☐ Text

☐ Email

☐ Either

Preferred Language: _______________________________________________________

Do you need an interpreter?

☐ Yes

☐ No

If yes, language needed: _______________________________________________________

Current City: _______________________________________________________

County: _______________________________________________________

ZIP Code: _______________________________________________________

Implementation Note
Do not require a full street address at the initial intake stage unless it is necessary for the specific service being requested.

 

Section 2 - What Assistance Are You Requesting?

Please select all that apply:

☐ Emergency Food Assistance

☐ Housing / Rent Assistance

☐ Temporary Lodging

☐ Transportation Assistance

☐ Resource Navigation

☐ Case Management

☐ Household Essentials

☐ Other:

Carol - Form Logic
Use conditional form logic so applicants only see questions relevant to the services they select.

 

Section 3 - Household Information

Number of adults in household: _______________________________________________________

Number of children under 18: _______________________________________________________

Total household size: _______________________________________________________

Are there children in the household?

☐ Yes

☐ No

Are there older adults in the household?

☐ Yes

☐ No

Does anyone in the household have a disability or mobility-related need that may affect service delivery?

☐ Yes

☐ No

☐ Prefer not to answer

No detailed diagnosis should be required.

Section 4 - Emergency Food Assistance

Show this section only if Emergency Food Assistance is selected.

 

Are you currently experiencing an immediate shortage of food?

☐ Yes

☐ No

How many people need food assistance? _______________________________________________________

Do you have enough food for the next 24-48 hours?

☐ Yes

☐ No

☐ Unsure

Are there children in the household needing food support?

☐ Yes

☐ No

Do you have transportation to pick up food if needed?

☐ Yes

☐ No

Would delivery be needed if available?

☐ Yes

☐ No

☐ Maybe

Are culturally appropriate foods important to your household?

☐ Yes

☐ No

If yes, please describe any preferences: _______________________________________________________

Do you need any non-food essentials?

☐ Cleaning supplies

☐ Laundry detergent

☐ Hygiene products

☐ Baby products

☐ Other:

Section 5 - Housing / Rent Assistance

Show this section only if Housing / Rent Assistance is selected.

 

What best describes your current housing situation?

☐ Currently housed but behind on rent

☐ Received landlord warning

☐ Received eviction notice

☐ Court or eviction date scheduled

☐ At risk of homelessness

☐ Temporarily staying with others

☐ Currently without stable housing

☐ Other:

Monthly rent: $ _______________________________________________________

Amount currently owed: $ _______________________________________________________

Have you received an eviction or landlord notice?

☐ Yes

☐ No

If yes, date of notice: _______________________________________________________

Deadline or court date, if known: _______________________________________________________

Landlord / Property Management Name: _______________________________________________________

Landlord / Property Management Phone or Email: _______________________________________________________

Have you already applied to another organization for rental assistance?

☐ Yes

☐ No

If yes, where? _______________________________________________________

Have you already received any assistance toward this same rent balance?

☐ Yes

☐ No

If yes, amount or source if known: _______________________________________________________

What caused the housing difficulty?

☐ Loss of employment

☐ Reduced work hours

☐ Unexpected expense

☐ Medical or health-related hardship

☐ Family emergency

☐ Increase in housing costs

☐ Other:

Implementation Note
Avoid asking applicants to upload sensitive documents on the first screen. Documents can be requested after initial review when appropriate.

 

Section 6 - Temporary Lodging

Show only if Temporary Lodging is selected.

 

Do you have a safe place to stay tonight?

☐ Yes

☐ No

☐ Unsure

How many people need lodging? _______________________________________________________

Are minor children included?

☐ Yes

☐ No

How long do you anticipate needing temporary lodging?

☐ One night

☐ 2-3 nights

☐ Less than one week

☐ Longer / Unsure

Are you currently staying in:

☐ A hotel/motel

☐ Shelter

☐ Vehicle

☐ With family/friends

☐ Outdoors

☐ Other:

Section 7 - Transportation Assistance

Show only if Transportation Assistance is selected.

 

What transportation assistance are you requesting?

☐ Transportation to housing or shelter

☐ Transportation to food assistance

☐ Transportation to an appointment

☐ Public transportation assistance

☐ Gas support

☐ Other:

Please briefly explain why transportation is needed:

_______________________________________________________

_______________________________________________________

Transportation support depends on available resources and program eligibility.

Section 8 - Resource Navigation / Case Management

Show when Resource Navigation or Case Management is selected.

 

What assistance do you need help locating or navigating?

☐ Housing resources

☐ Food assistance

☐ Utility assistance

☐ Transportation

☐ Employment resources

☐ Benefits

☐ Health or wellness referrals

☐ Legal-service referral

☐ Family support services

☐ Other:

Have you already contacted any agencies regarding this need?

☐ Yes

☐ No

If yes, please list them: _______________________________________________________

Section 9 - Urgency

How urgent is your current need?

☐ Immediate - today

☐ Within 24-48 hours

☐ Within one week

☐ Ongoing / preventive need

Are you or members of your household currently without food, housing, or another essential basic need?

☐ Yes

☐ No

Is there an immediate safety concern?

☐ Yes

☐ No

If yes, briefly describe: _______________________________________________________

PATH is not an emergency-response service. If you are experiencing an immediate life-threatening or safety emergency, contact the appropriate emergency service provider.

 

Section 10 - Financial Hardship

Has your household experienced a recent financial hardship?

☐ Yes

☐ No

If yes, select all that apply:

☐ Job loss

☐ Reduced hours

☐ Medical expenses

☐ Unexpected emergency

☐ Housing-cost increase

☐ Transportation issue

☐ Family change

☐ Other:

Are you currently receiving income?

☐ Yes

☐ No

☐ Prefer not to answer

Detailed income verification should be requested later only when required for eligibility or a funding source.

Section 11 - Referral Source

How did you hear about PATH?

☐ 211

☐ Friend or family member

☐ Community organization

☐ County or government agency

☐ Church / faith community

☐ Social media

☐ PATH website

☐ Returning PATH participant

☐ Other:

If referred by an organization, please list the organization if known: _______________________________________________________

RFP / Reporting Value
Referral-source data is important for partnership reporting, service-demand analysis, and future RFPs.

 

Section 12 - Other Assistance Requested or Received

Have you requested assistance for this same need from another organization?

☐ Yes

☐ No

If yes, organization: _______________________________________________________

Type of assistance requested: _______________________________________________________

Status:

☐ Pending

☐ Approved

☐ Denied

☐ Unsure

Section 13 - Additional Information

Please briefly describe your current situation and how PATH may be able to assist you:

_______________________________________________________

_______________________________________________________

_______________________________________________________

Section 14 - Consent and Acknowledgment

Before submission, applicants should acknowledge:

☐ I understand that submitting this form does not guarantee financial assistance or services.

☐ I understand that PATH may contact me to request additional information or documentation.

☐ I understand that PATH may refer me to another organization if PATH is unable to provide the requested service directly.

☐ I certify that the information I have provided is accurate to the best of my knowledge.

☐ I understand that PATH will use the information provided to review my request, coordinate assistance, and maintain appropriate program records.

Applicant Name: _______________________________________________________

Electronic Signature / Typed Name: _______________________________________________________

Date: _______________________________________________________

Section 15 - Privacy Notice

PATH respects the privacy of individuals seeking assistance. Information submitted through this form will be used to review your request, coordinate services, make appropriate referrals, document program activity, and meet applicable funding or reporting requirements. PATH will limit access to individuals who have a legitimate program, administrative, financial, or compliance need.

Please do not upload highly sensitive legal, medical, financial, immigration, or identity documents unless PATH specifically requests them through an appropriate process.

 

Internal PATH Staff Section

This section should not appear on the public-facing form.

 

Date Received: _______________________________________________________

Case Number: _______________________________________________________

Assigned Staff: _______________________________________________________

Primary Need:

☐ Food

☐ Housing

☐ Lodging

☐ Transportation

☐ Resource Navigation

☐ Multiple Needs

Urgency Level:

☐ Priority 1

☐ Priority 2

☐ Priority 3

Referral Source: _______________________________________________________

Initial Determination:

☐ Direct assistance review

☐ Case management

☐ Referral

☐ Pending documentation

☐ Unable to assist

☐ Closed

Funding Source Used, if applicable: _______________________________________________________

Follow-Up Required:

☐ Yes

☐ No