Request for Assistance

Clackamas County is committed to helping residents who have been directly impacted by the wildfires connect with critical resources. If you are in need of assistance please reach out EOCEvacuationFire@clackamas.us or 503-650-3561.

For non-wildfire related housing assistance, please reach out to Coordinated Housing Access at https://www.clackamas.us/communitydevelopment/cha or 503-655-8575

This form will be used to evaluate your specific needs and allow us to provide more appropriate resources in some cases. If you are unable to submit the form or need assistance completing the form, please call 503-650-3561 and leave a message — you will be contacted within 1 business day (Monday through Thursday).

If you are having an emergency, call 9-1-1

Question Title

* 1. Who is filling out this form?

I am filling this form out for myself/family

I am filling this form out on behalf of a resident/family

Question Title

* 2. Contact Information

Name

Primary Phone

Alternate Phone

Address

City

State

Zip

Question Title

* 3. Your relationship to the person or family seeking help?

Question Title

* 4. How many individuals need help?

Question Title

* 5. Number of individuals in the household age 18 years or younger?

Question Title

* 6. Number of individuals in the household age 65 years or older?

Question Title

* 7. Current Housing Situation

Question Title

* 8. Veteran or Spouse of Veteran

Yes, I served in the military

I am/was married to someone when they served in the military

No, I did not serve in the military

Question Title

* 9. What kind of unmet needs do you have? Check all that apply

Food resources

Home repairs or smoke remediation

Housing/rental assistance

Clothing, toiletries, personal hygiene items

Transportation

Veteran's benefits

Medical health care

Mental health care

Energy assistance/utilities

Help with federal financial aid or assistance

Medicaid/OHP

Other (please specify)

Question Title

* 10. How long do you anticipate needing assistance?

1 month

2 months

3+ months

I don't know

Question Title

* 11. Comments

Question Title

* 12. I agree with the statement below.

Yes

I hereby authorize Clackamas County to release to nonprofit disaster relief entities that coordinate with Clackamas County on 2020 wildfire response and recovery activities, including participants in the Clackamas County Fire Resource Center, certain information maintained by Clackamas County that is relevant for the purpose of providing assistance for my needs. This authorization will allow Clackamas County to share my contact information (name, telephone number, address, email, household size, housing situation, and unmet needs (financial assistance, housing assistance, rebuilding assistance, food assistance, etc.) with non-profit organizations coordinating with Clackamas County on response and recovery.