Advocacy Intake Form

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Please complete this form as honestly and completely as possible. All information that you provide is secure and confidential as required by state and federal law.

Feel free to upload any documents you feel are essential to understanding your situation and circumstance.

You will be contacted within 24 business hours, usually the same day.

Personal Information

First Name

Last Name

Street Address

City

Street Address Line 2

State

Postal / Zip code

Contact Information

Cellphone

Home Phone

Other Contact Info

Preferred Contact Time: Select One

Morning

Afternoon

Evening

Any Time

Preferred Contact Method: Select One

Home Phone

Cellphone

Text Message

Additional Information about Contacting You (optional)

Additional Information

Are you a Crowd Proud client?

Are you a Veteran?

Select the MAIN reason for the nature of your request?

Children & Youth Services (CPS)

Probation

Parole

Utility Shut-Off Notice

Utilites Shut Off

Other (please explain below)

If CPS, what county?

Please provide a brief summary of the reason(s) for your request.

Feel free to upload any important documents. Note: There is a maximum limit

Upload File

Upload supported file (Max 15MB)

This Intake Form is part of Crowd Proud's mission to Advocate and Support

Thank you for submitting your form!

Join Crowd Proud's Email List!

570.763.8282

Crowd Proud is a woman founded and operated, nonprofit corporation providing life-saving advocacy, services, and compassion to strengthen the rural, low-income, underserved individuals, families, children, and military veterans.

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