Participant Intake

Complete this form to connect with our case managers and access SAFE programs.

Personal Info

Needs

Goals

Personal Information

Full Name *

Date of Birth *

Gender

Email Address *

Phone Number *

Mailing Address

Street Address *

City *

ZIP Code *

Emergency Contact

Name

Phone

Relationship

Needs Assessment

Current Living Situation *

Housed (stable)Staying with family/friendsTransitional housingUnhousedOther

Employment Status *

Employed full-timeEmployed part-timeUnemployedUnable to work

Justice System Involvement *

YesNoPrefer not to say

Programs of Interest

SAFE Smart DrivingYouth MentorshipReentry ConnectionCommunity WorkshopsHomeless OutreachLegal Aid

Briefly describe your situation *

Goals & Submission

30-Day Goals

60-Day Goals

90-Day Goals

How did you hear about SAFE?

I consent to SAFE Foundation collecting and storing this information to assist with my case management. *
Your information is strictly confidential and used only to connect you with services.

SAFE Foundation

Streets Ain't For Everybody

We're on a mission to serve lives, restore hope, and rebuild communities one person at a time

Programs

Smart Driving
Youth Mentorship
Reentry Support
Homeless Outreach
Legal Resources
Workshops

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