Chaves County 211 Unmet Needs Assessment

1. READ BEFORE YOU START

Clients (Adult) may only submit one application per household. This intake application is intended to assess the unmet needs of the community from the flood disaster on October 19, 2024.

After submitting your application, a case manager will reach out to you to discuss next steps and request any additional supporting documentation that may be needed to move forward.

RELEASE OF INFORMATION:

- By completing this intake application, I understand that my personal and household information may be shared with agencies, entities and local partners, as necessary, to support my recovery.

14% of survey complete.

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* 1. Name

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* 2. Current mailing address

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* 3. Which describes your CURRENT housing type/situation?

Shelter

Apartment/Condo

Single Family Home

Mobile Home

Recreational Vehicle (RV)

Hotel/Motel

Multi-Family Home

Homeless

Vehicle

Other (please specify)

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* 4. Is current housing location long term?

Yes

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* 5. Best Contact Number

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* 6. Best Contact Information

Anytime

Morning

Afternoon

Evening

Other (please specify)

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* 7. Do you still have unmet needs due to the flooding?

Yes