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Self-Referral
If you are looking for help from Karlee's Home Team please fill out as much of the form as you can - Or email info@karleeshometeam.com
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* Indicates required question
Name and best way to contact you (phone, email, Facebook)
*
Your answer
How did you hear about us?
Friend/Family Member
Local Welfare Department
Community/Social Service Provider - CAP, Waypoint, 211, other shelter
Peer Support Agency - i.e SoS or Infinity etc
Food Bank Program - i.e Gerry's/ShareFund, Manna meals, Gather
Faith Based Organization
Police Department
Other:
Location where you can be found if no phone/Facebook
*
Sos - Dover
Sos - Rochester
Infinity Peer Support
Rochester Fellowship Kitchen
CAPSC
Willand Warming Center
Welfare Office
Other:
Required
What are your needs? (Please check all that apply. Note that while we may not provide all these items directly, we will connect you with partner agencies where appropriate.)
*
Survival items - Tent, tarps, blankets etc...
Hygiene items
Weather appropriate clothing
Food
Transportation to other providers/programs
Care Coordination/Case Management (benefits, housing, program/resource navigation)
Accessing emergency shelters
Health Care Services
Recovery/Mental health supports
Employment Resources
Other:
Required
Please use this space to share any additional information that could help us better assist you during this challenging time
Your answer
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