Pine Hills Community Foundation

Needs Assessment & Referral Form

KNOW MORE. CARE MORE. DO MORE.

Identify your immediate needs and, with your permission, connect with appropriate community resources.

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KNOW MORE. CARE MORE. DO MORE.•Investing in people, places and partnerships that strengthen Pine Hills.People • Places • Partnerships • Pine Hills

You may request information without agreeing to partner sharing or follow-up. If you provide an email address and permit PHCF to contact you, we will email a confirmation even if phone or text is your preferred method. Please provide only what is needed to help with your request.

Online submission is being connected. Please contact PHCF for assistance, or dial 211 for immediate resource information.

1. Contact Information

Best way to reach you

2. Household & Housing Situation

Household
Current situation
Do you have a safe place to stay tonight?

3. Help Needed Today

Check only what applies

4. Urgent Safety Screen

For a life-threatening emergency, call 911. Dial 211 for emergency shelter information and referral services. This form is not monitored for emergencies. PHCF is not an emergency shelter, healthcare provider, or crisis-response agency.
Select what applies. Do not include sensitive details.

5. Referral & Communication Permission

Please choose one or more, as applicable

For assisted intake, verbal consent must be documented by an authorized PHCF representative in the private referral record.

Confidentiality: PHCF collects only information reasonably needed for referral and follow-up. Do not provide Social Security numbers, driver’s license or ID numbers, full date of birth, immigration status, medical information, or other sensitive details. Identifying information is shared with approved providers only with permission or as otherwise required by law.

PHCF / Partner Use Only: referral made to, resource/service, date/method, follow-up status, and documented verbal consent are maintained in the private referral record.