Intake form

Name *

Email address *

What services do you need assistance with?

Please select at least one option.

Eviction Prevention

Housing Support

Mental Health Services

Substance Abuse Assistance

Homelessness Support

Are you currently facing eviction?

What is your current housing situation?

Do you require immediate assistance?

What is your age group?

How did you hear about us?

Please select at least one option.

Social Media

Referral

Online Search

Community Event

What is your zip code?

Do you have any specific needs or preferences we should know about?

Which service or services are you interested in?

Please select at least one option.

Eviction prevention assistance

Substance abuse support

Mental health advocacy

Active advocacy for better benefits for the disabled

Additional questions or comments

BJG COMMUNITY JUSTICE NETWORK