Resource Request Intake Form

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

All requests are initiated by a partnering agency via email. The intake form must be completed and sent to sylvia@jamessamaritan.org. This form may also be found on our website at www.jamessamaritan.org. The intake form must be completed in order to receive assistance. Completing the form is NOT a guarantee of assistance.

Note 1: James Samaritan exists to provide support and services to the foster care community. In order to continue serving this community for years to come, it is necessary to limit the distribution of resources to individuals who are currently involved in the foster care system.

Note 2: James Samaritan is not currently able to accept requests that are urgent in nature. Requests for housing, rental assistance, transportation, and other urgent needs or ongoing needs will not be considered as we do not have the capacity to meet needs at this level.

Note 3: James Samaritan will review the request upon receipt of the intake form and respond to the referring agency regarding James Samaritan’s ability to meet the requested need.

Thank you for your dedication in serving children and families from hard places. We appreciate any feedback you may have about this process or about how James Samaritan has impacted a client in a positive way. All feedback is helpful to us as we continuously strive to improve and is a great encouragement to those who support and fund our organization.

Email *

Record my email address with my response

Referring Agency *

Caseworker Name *

Caseworker Phone Number and Email *

Parish and/or Region *

Caregiver's Name, Address and Phone Number *

Race/Ethnicity *

African American

Asian

Caucasian

Hispanic

Non-Hispanic

Other:

Required

This Placement is a *

Certified Foster Home

Kinship Foster Home

Extended Foster Care Youth

Group Home

Independent Living

Biological Family

Other:

Required

Please describe the type of assistance you are requesting below (BE VERY SPECIFIC): *

Will this resource help facilitate or maintain a kinship placement? *

Will this resource help facilitate a foster youth in achieving independence? *

Will this resource help facilitate a biological parent keeping their child(ren) in or returning their child(ren) to their custody? *

Is this client/family currently enrolled in any other program to assist with these needs? *

Client (child's) name, age and relationship to the caregiver: *

Clear form

Never submit passwords through Google Forms.

This form was created inside of James Samaritan. Report Abuse

Forms