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.

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

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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