Case Management

Client Intake Form for Case Management - Part One

In order to know how to best assist you, we need some basic information about you, your background, and your present circumstances. Our Case Managers will review your information and respond back to you.

Full Legal Name (Required)

Date of Birth (Required)

E-mail Address (Required)

Phone Number

Marital Status (Required)

How long have you been on the streets? (Required)

Reason you have been on the streets (Required)

Have you been convicted of felony or misdemeanor? (Required)

Are you on parole or probation? (Required)

Physical or mental health conditions you have: (Required)

Medications you take:

Do you want help with an addiction issue? (Required)

Are you interested in enrolling in our Radical Life Transformation Mentoring and Training Program? (Required)

Name of your emergency contact: (Required)

Phone / Email of Contact: (Required)

Application Notes:

Nothing in this application shall be construed as a contract or guarantee. Information is used to determine applicant fitness for assistance, mentoring, emergency shelter admission, or temporary housing program.
Information shall be handled as confidentially as possible with GUUM Team Members and used to make decisions concerning applicant in regard to participation in assistance and volunteering.
Any information applicant provides that is false, incomplete or deceptive by what is reported or not reported is grounds to terminate assistance without notice. Applicant affirms all information is true.