Crisis Assistance Form

Need help? Please reach out here - you are not alone!

Please fill out this form if you're experiencing any hardship that we don't have a direct resource for, or if you just need someone to talk to. We are here to support you however we can! We can connect you with appropriate resources or give you a call just to chat!

All responses will be directed to Dianne, BSW, who is the Assistant Outreach Coordinator. She will reach out to you to follow up and get to know you and your needs!

Your honesty about your situation is crucial so we can ensure we find the correct resources for you! Your answers will not affect the food/medication services you receive from us, and your responses will be kept confidential except in the threat of harm to yourself and/or others. Basic information may be shared with necessary colleagues to ensure continuity of services.

DISCLAIMER: THIS IS NOT A COUNSELING SERVICE. FOR COUNSELING/THERAPEUTIC NEEDS, PLEASE CONTACT A LICENSED MENTAL HEALTH PROFESSIONAL. THIS SERVICE IS NOT INTENDED FOR USE DURING AN IMMEDIATE EMERGENCY. FOR EMERGENCY SERVICES, PLEASE CALL 911.

First Name

Last Name

Explain your situation in as much detail as possible.

Is there anything specific we need to know about your situation? Any deadlines, health concerns, specifications, etc?

What are your goals/ what is your ideal situation?

Do you have the following things?

Select an option

Clean Water

Heating/ AC

Electricity

Are you currently homeless or at risk of becoming homeless?

Select an option

Yes

What is your preferred method of contact?

Select an option

Phone Call

Text

Phone

Birthday

Do you consent to details about your case (your name/situation) being shared with other Hunger and Health staff in the event that collaboration is needed? This may be necessary to ensure we provide you the highest quality of assistance.

Select an option

Yes, you can share my information with others at the HHC.

PLEASE READ THE ENTIRE SECTION:

This is not a counseling or therapy service. For any mental health concerns, please contact a licensed mental health professional.

This is not intended for use in the case of an emergency. For emergency services, please call 911.

The Hunger & Health Coalition cannot provide money to help pay for any financial situations. We can reach out to other agencies/benevolence groups on your behalf, but we cannot guarantee funding from these agencies.

All client interactions will be documented in the form of case notes. Clients reserve the right to request a copy of these notes, if necessary. Case notes are recorded in a HIPAA compliant software system.

Clients reserve the right to refuse services at any time, for any reason, without any explanation.

All staff at the Hunger and Health Coalition are mandated reporters. Staff are required to report any suspicion/evidence of child abuse/neglect to the local DSS office and to local law enforcement.

This is a free service! We cannot accept any kind of payment in exchange for services.

Please sign your name in the box below to signify that you have read and understand all of these things. Please reach out to us with any questions at 828-262-1628 and ask for Dianne. For pharmacy specific questions, please call 828-264-5212.

Your Signature

Thanks for submitting!