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BeGenerous, Inc. Full Application
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* Indicates required question
1. PERSONAL INFORMATION
Who is filling out this form?
*
I am filling out this form for myself
I am filling out this form for another person. If so, please give us your name, phone and organization in the other option below.
Other:
Name
*
Your answer
Phone Number
*
Your answer
Email
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Do you have a Driver's License?
*
Yes
No
Do you have an Emergency Contact? (Name and Phone)
Your answer
2. IMMEDIATE NEEDS
Emergency Medical Help Needed
*
No urgent medical help needed
I need a Rape Kit and STD Check
I'm injured and need to get to an ER
Other:
Do you have any medical Conditions?
*
Your answer
What is your mental health status? (Diagnosis)
*
Your answer
Are you currently on any medications?
*
Your answer
Do you have Health Insurance?
*
Yes
No
Do you need urgent clothing, food or toiletries?
Your answer
Do you need emergency housing? (shelter or safe home)
*
Yes
No
Other:
3. SUBSTANCE ABUSE
Are you currently experiencing substance abuse?
(No judgement. We want to help with detox if needed)
*
No Substance Abuse in over a month.
Cocaine
Crack
Meth
Fentanyl
Marijuana
Heroin
Percocet
Oxy
Xanax
Ecstasy / Molly
Alcohol
Other:
Required
When was the last time you used? What is the amount and frequency?
Your answer
4. CURRENT INVOLVEMENT
Are you working with any other nonprofits, ministries or advocates who are helping you? (Please share the names and contact info)
*
Your answer
5. LEGAL
Do you have any upcoming court dates or legal situations? Are you currently on Probation?
*
Your answer
FOR SEX TRAFFICKING SURVIVORS - Have you made a report to the Human Trafficking Hotline or Local Law Enforcement? (please share the case numbers)
Your answer
RELEASE OF INFORMATION - I authorize BeGenerous, Inc. to both share and receive my information with relevant service providers for the purpose of securing resources on my behalf and providing advocacy.
*
Yes
No
Thank you for completing the BeGenerous, Inc. Full Application. Someone will get back to you asap. If you are in an emergency, please see the resources listed on our website, at the bottom of our "Contact" page.
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