Case Management Request Form

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This form is to be completed for any cases that might benefit from ongoing support from our Community Support Manager (aka Social Worker).

Examples might include:

1) Pet owners with pregnant or nursing moms that we would like to work towards surrendering puppies/kittens.
2) Overwhelmed caregivers/hoarding situations
3) Clients with pets who have been seen/treated in the clinic with substantial or ongoing medical needs (i.e. congestive heart failure due to heartworm disease)
4) Clients who have had pets who we have seen in various stages of neglect that need ongoing support.
5) Clients whose pets may suffer due to mental or physical illnesses, substance abuse, etc. that could be prevented through regular communication.
6) Clients experiencing a major crisis that would benefit from being connected to other services beyond pet related services (i.e. homelessness, domestic abuse, etc.)

Note: A receipt from this form is not sent to the client after completion.

Type of request *

GPG staff member requested case management support

GPG volunteer requested case management support

Animal control requested case management support

Shelter diversion

Other:

Required

Type of request *

Pet owners with pregnant or nursing moms that we would like to work towards surrendering puppies/kittens.

Overwhelmed caregivers/hoarding situations

Clients with pets who have been seen/treated in the clinic with substantial or ongoing medical needs (i.e. congestive heart failure due to heartworm disease)

Clients who have had pets who we have seen in various stages of neglect that need ongoing support.

Clients whose pets may suffer due to mental or physical illnesses, substance abuse, etc. that could be prevented through regular communication.

Clients experiencing a major crisis that would benefit from being connected to other services beyond pet related services (i.e. homelessness, domestic abuse, etc)

Other:

Required

Requester's last name *

Requester's first name *

Owner's last name *

Owner's first name *

Owner's street address *

Owner's zip code

62201

62202

62203

62204

62205

62206

62207

Other (Note: This form should only be submitted if clients live in the zip codes above)

Clear selection

Owner's phone number (include area code)

Owner's email

Case summary

Name of person who submitted this form *

What happens next?

Once the Community Support Manager receives the request, they will make contact with the owner within 14 days of the request unless it is noted in the summary that the situation requires more timely contact.

Submit

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