Submit My Information

Please fill out the following form as best as you can. A member of the SMAC team will contact you shortly after you submit your responses.

Name

First Name

Last Name

Phone

(###)

###

####

County

What county are you in right now?

Age

Gender Pronouns

She/Her, He/Him, They/Them, etc.

Household size

Number of aduls (18+)

Number of children (17 and under)

Have you ever served in the U.S. Military?

Is anyone currently trying to harm you, control your daily activities, or force you to do things you do not want to do?

In the past 7 days, where have you been sleeping?

Confidentiality

This information may be seen by several members of the SMAC team in order to provide you with the help you are requesting

I understand