Camp Fire Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Para completar este formulario en Español: http://bit.ly/211entrada

The Camp Fire Collaborative (previously the Camp Fire Long Term Recovery Group (Camp Fire LTRG)) is a collaboration of organizations working to address unmet needs of fire survivors. This form helps connect survivors to resources that offer assistance with long term recovery. Please complete this Intake Form to be considered for disaster case management and other fire recovery programs. Please read the following so that you understand the limitations of this form and the limitations on resources.

- After you complete the form, you will be placed on the Community Queue (wait list for disaster case management).
- Currently there is no immediate access to a case manager since there is a very long wait list of survivors and not enough case managers available to take new cases.
- Survivors are referred to case management agencies from this intake list in the order in which their intake was received.
- Filling out this form does not guarantee access to recovery resources.
- Certain documentation from you may be requested later to confirm eligibility for specific recovery programs.
- In response to this form, you may receive communications from local disaster recovery agencies by text, phone, or email. Please be sure to check your messages frequently.
- If you have already completed this form, you do not need to fill it out again.
- Only submit an update to this form if you have a change in your contact information: phone number, email address, physical address.

First Name *

Last Name *

Best Phone Number: *

2nd Phone Number

Email Address

Gender *

Date of Birth *

What is the best way to reach you? *

E-mail

Phone

Other:

Required

What is the best time to contact you?

Morning 7:30am to 12 Noon.

After 12 Noon to 6:00 pm.

Saturdays

Anytime.

Do you already have a case manager that you are working with currently for your recovery from the Camp Fire? *

Yes

Not sure

Other:

Do you consent for your information to be shared with other agencies such as disaster case management services and financial assistance programs to help Camp Fire Survivors meet their immediate and long term needs? (This includes agencies operating under the Camp Fire Collaborative {Previously the Camp Fire Long Term Recovery Group} such as Caring Choices, United Way, Youth for Change, Northern Valley Catholic Social Services, the Jesus Center, Tzu Chi, St. Vincent de Paul, North Valley Community Foundation, and others, as well as the Butte County Department of Employment and Social Services) *

I consent.

I do not consent. (Please note that consent is required for your information to be shared with agencies providing disaster case management and financial assistance.)

Clear form

Never submit passwords through Google Forms.

This form was created inside of Help Central Inc.. Report Abuse

Forms