Community Action Coalition Intake Form

Fill out the form below to apply for services with the CAC. An Intake Specialist will reach out to provide assistance. This information is not required, but it helps us assess and meet your needs.

CAC Intake Form

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Contact Information

(page 1 of 3)

Who is submitting this form? *

Self
Friend or Family Member
Outside Caseworker
CAC Staff

Your Contact Information

If you are completing this form on the behalf of a someone else, please first include your contact information in the following fields.

Your Name

First

Last

Your Email

Your Phone Number

Name of your Organization

CAC Staff Information

This option is for CAC staff members to log client intake internally. Please only use this option if you are an employee at CAC.

CAC Employee Name *

First

Last

For CAC Staff Only

Intake Method *

For CAC Staff Only

Client Information

Please complete the following fields about the person looking for assistance or services.

Name

First

Last

Where are you located? *

Dane County
Jefferson County
Waukesha County
Other

ZIP Code

What is your most reliable address? (Street, City, State)

Address Line 1

Address Line 2

City

State

Phone Number

How can we help?

(page 2 of 3)

1. What type of support are you looking for? *

Housing / Utilities
Food and Nutrition
Transportation
Clothing and Household Essentials
Family, Child, and Senior Support
Health (mental or physical)
Financial Assistance / Benefits
Employment and Income
Education and Training
Other

Housing / Utilities: What would you like help with? (check all that apply) *

Rental Assistance
Security Deposit
Energy Assistance or Utilities (gas/heat, electric, water/sewer)
Eviction Prevention
Affordable Housing Search
Low Income Housing
Homelessness / No Place to Stay
Hotel Voucher
Emergency Shelter
Landlord Dispute
Tenant Rights or Eviction Questions
Mortgage Assistance
Home Repair
Moving Assistance
Other

Food and Nutrition: What would you like help with? (check all that apply) *

SNAP / FoodShare
Food Pantry
Meal Sites
Double Dollars
WIC
Baby Formula/Food
Other

Transportation: What would you like help with? (check all that apply) *

Gas Voucher/Card
Bus Pass
Vehicle Repair
Car Insurance
Ride Coordination
Driver's License Issues
Other

Clothing and Household Essentials: What would you like help with? (check all that apply) *

Free Clothing Center
Winter Clothing (Winter Glow, Koats for Kids)
School Supplies or Clothes
Work Clothes
Hygiene Products or Household Supplies
Baby Supplies or Diapers
Pet Food Assistance
Other

Family, Child, and Senior Support: What would you like help with? (check all that apply) *

Finding Childcare
Childcare Payment Assistance
Parenting Support
Youth Programs
School Supplies
Pregnancy Support
Senior Services
Disability Support Services
Other

Health: What would you like help with? (check all that apply) *

Healthcare Navigation
Health Insurance Enrollment
Mental Health Support
Substance Use Treatment
Medical Bills or Debt
Medical Care
Dental or Vision Care
Senior Services
Disability Support Services
Other

Financial Assistance / Benefits: What would you like help with? (check all that apply) *

Budgeting
Financial Counseling
SSI / SSDI Assistance
Tax Prep Assistance
Benefit Application Assistance
Emergency Financial Assistance
Other

Employment and Income: What would you like help with? (check all that apply) *

Job Search Assistance
Resume Help or Interview Preparation
Job Training
Employment Supplies (uniform, work boots, equipment)
Unemployment Benefits
Other

Education and Training: What would you like help with? (check all that apply) *

GED / Adult Education
English Language Learning (ESL)
Vocational Training
College Planning
Financial Aid Assistance
Computer or Technology Classes
Youth Education
Other

Other: What would you like help with? (check all that apply) *

Identity Documents (birth certificate, ID)
Immigration Referral
Legal Help
Domestic Violence
Community Resources
Volunteer Opportunities
Make a Donation
Other

2. What other challenges is your household facing? Please describe:

3. What is the biggest barrier making it difficult to address these challenges?

Not enough income to meet basic needs
Transportation challenges
Housing instability or homelessness
Cost of housing
Difficulty finding employment
Lack of education, training, or job skills
Childcare (unavailable, unaffordable, or doesn't fit my schedule)
Mental health challenges
Long waitlists
Services are not available or accessible to me
Not eligible for services
Disability or accessibility needs
Language barriers
Recent crisis or emergency (eviction, job loss, illness, disaster, etc.)
Other
Prefer Not to Say

Demographics

(page 3 of 3)

Have you applied for CAC services before?

What was your household income last month?

How many adults are in your household (including yourself)?

Employment would with?

How many children are in your household?

Gender:

Age:

Race:

Ethnicity:

Highest Education Level Completed:

Employment Status:

Military Status:

Do you have a disability?

Housing Situation:

Languages Comfortable Speaking:

Is there anything else you would like to share?

Once you click ‘submit’ we will review your information and be in touch shortly. Thank you!

Community Action Coalition Intake Form

Contact Information

Your Contact Information

CAC Staff Information

Client Information

How can we help?

Demographics

Office Locations

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