Social worker/case manager/SFA Name
*
First Name
Last Name
Referral Agency (select from list)
*
Select one
Abbe Mental Health Center/Unity Point
Access 2 Independence
Amerigroup
BHS
Caring Hands & More
Catholic Worker House
Cedar Valley Community Support Services
Center for Worker Justice
Coralville Community Food Pantry
Community & Family Resources (formerly Prelude)
Department of Corrections - 6th District
Domestic Violence Intervention Program
Faith Academy
Families Inc
Four Oaks - IHH
Goodwill of the Heartland
Heritage Area Agency on Aging
IC (Iowa City) Compassion
IMPACT
Inside Out Reentry
Iowa City Community School District
Iowa City Police Department
Iowa Total Care
Johnson County General Assistance
Johnson County Mental Health/Disability Services
Johnson County Aging Services
Johnson County Social Services
MAT/South Bridge
Neighborhood Centers of Johnson County
Open Heartland
Prelude Behavioral Services
R Place Peer Recovery
RWRRP
Salvation Army's Veteran Housing Program
United Action for Youth
Unlimited Abilities
VA Hospital
Women's Health Center
If you are from ICCSD, please tell us which school:
Social Worker/Case Manager/SFA email
*
Head of Household First Name
*
Head of Household Last Name
*
Pronouns
Head of Household Date of Birth
*
MM
DD
YYYY
Street Address (including apartment number)
*
City
*
Iowa City
Coralville
North Liberty
Hills
Tiffin
Head of Household Phone Number
*
(###)
###
####
Prefers text or call?
*
Text
Call
Head of Household Email
Language(s) spoken in the home:
*
If the primary language spoken in the home is not listed above, please indicate the language spoken:
Alternate Contact Name
*
Alternate Contact Phone Number
*
Number of adults in household
*
Number of school-age children (ages 5-18) in household
*
Number of children younger than 5 in household
*
Does anyone in this household need a bed?
*
yes, one or more people in this household needs a bed
no, they have a bed or beds already
Number of TWIN beds needed
0
1
2
3
4
5
6
If you have requested one or more TWIN beds, please indicate the age and gender (if known) of each child or adult who will be sleeping in a twin bed.
Number of FULL beds needed
0
1
2
3
4
5
6
If you have requested one or more FULL beds, please indicate the age and gender (if known) of each child or adult who will be sleeping in a full bed.
Number of QUEEN beds needed
0
1
2
3
4
5
6
If you have requested one or more QUEEN beds, please indicate the age and gender (if known) of each child or adult who will be sleeping in a queen bed.
King size beds are unavailable
ok
Does the household have air mattresses to sleep on while waiting? Note: We do NOT provide air mattresses.
Comments or information about the household
*
Please share information that will be helpful to us when we contact the head of household, set up the pre-delivery visit, and deliver. Helpful information includes age, personality, circumstances, and any possible safety concerns. This information will not affect the services received.
Are items other than beds needed?
*
yes
no
not sure
List of other items needed or requested. Please note that what we can provide depends on inventory and other factors, so receipt of every requested item is not guaranteed. Also note that we have a limited number of dressers and can usually deliver only one per household.
Please only list items needed, separated by commas. Information should go in the "Comment or Information" field.
Is anyone in the household a smoker? (This does not affect which items are provided. We have staff who are allergic to smoke and appreciate knowing ahead of time.)
*
Yes
No
Unknown
Please estimate this household's income level:
*
Extremely low income (30% Average Median Income)
Very low income (50% Average Median Income)
Low income (80% Average Median Income)
>/= 100% Average Median Income
Unknown
Please note: The questions below do not affect anyone's ability to receive our services. We are collecting this information to get a more accurate assessment of who we are serving.
In the past 12 months, has this family or individual been in any of the following living situations because of economic hardship? Please check all that apply.
*
If other, please explain:
*
If sheltered locally, please tell us which shelter (select all that apply):
*
In the past 12 months, has this family or individual received assistance from another organization to help furnish the home?
*
Yes
No
Unknown
If yes, this household has received assistance from another organization to help furnish the home, please list the organization(s):
*
