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SAFE Foundation
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First Step
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 *
Month
January
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Year
2026
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1926
Gender
Select...
Male
Female
Non-binary
Prefer not to say
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/friends
Transitional housing
Unhoused
Other
Employment Status *
Employed full-time
Employed part-time
Unemployed
Unable to work
Justice System Involvement *
Yes
No
Prefer not to say
Programs of Interest
SAFE Smart Driving
Youth Mentorship
Reentry Connection
Community Workshops
Homeless Outreach
Legal Aid
Briefly describe your situation *
Goals & Submission
30-Day Goals
60-Day Goals
90-Day Goals
How did you hear about SAFE?
Select...
Friend / Family
Internet / Social Media
Court / Probation / Parole
Community Partner / Shelter
Other
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.
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