Client Intake – Another Chance

to our Prospective clients

What does your dream look like?

What about your past do you feel may be an obstacle that would prohibit you from reaching your desired dream life?

How We Help

Empower underserved individuals to reach their fullest potential by providing a safe environment, safe housing, educational support, employment training, and self-sufficiency skills.

Take the first step

We will help match you to available community resources. The first step is to request a client intake form by completing the fields below. An email will be sent to you shortly.

"*" indicates required fields

Name*

First Name Middle Name Last Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone Number

Format (###)###-####

Sex

Age on Event Date

In case of Emergency

Emergency Contact*

First Name Last Name

Relationship

Contact Number

(###)###-####

Release and Waiver of Liability - Assumption of Risk and Indemnity Agreement

Hac aliquam risus orci justo integer tristique consequat tellus vel lobortis Lacinia lobortis nisl vehicula purus cursus Nisl neque fusce eleifend mollis porttitor etiam congue felis ad eros quisque eleifend Fames viverra leo molestie enim purus dui hac phasellus vel etiam quisque nullam Curabitur vehicula vivamus congue dui at nunc et ligula massa Curae dictum lorem velit vulputate scelerisque netus eu curabitur odio pulvinar etiam Dictum sed erat auctor amet mollis nullam consequat suspendisse mattis Vel hendrerit sed hendrerit ut a platea

Signature*

to our Prospective clients

What does your dream look like?

How We Help

Take the first step

Another chance: House of Refuge

Another Chance