Help - Big Bend Continuum of Care

Please contact The Kearney Center by calling 850-792-9000. You can also visit https://kearneycenter.org/need-help/#services for more information.

Please contact Family Promise of the Big Bend by calling 850-576-5566. You can also visit familypromisebigbend.org/get-help/ for more information.

Please contact Capital City Youth Services by calling 850-576-6000. You can also visit ccys.org for more information.

Please contact Refuge House by calling 850-681-2111. You can also visit https://refugehouse.com/get-help/ for more information.

You may also wish to call 211 for crisis counseling services.

Additionally, https://www.findhelp.org provides access to food pantries, medical care, and other free or reduced-cost help.

For more resources, please download our Resource & Service Guide

If you would prefer that we refer you to one of these agencies directly, please provide us your information below.

Client Referral Assessment

The information provided here will be used to identify the most appropriate community agency to provide assistance. Your data will be stored safely, and will be disposed of securely after the referral has taken place.
Client Name: *

First Name Middle Name Last Name Suffix
Date of Birth: *

Month Day Year
Phone Number *
Please enter a valid phone number.
Email
example@example.com
How would you prefer to be reached? *
Gender *
Primary Race: *
Ethnicity: *
In what county do you currently reside? *
In what language do you feel best able to express yourself? *
In a few words, how can we help? *
Employment Status *
Total Monthly Income (if applicable) *
Mark $0 if no income
Source(s) of Income (if applicable) *
Current living situation *
Where did you sleep last night?
If you are currently housed, but at risk of becoming homeless, how soon will you lose your housing?
If renting, what is your monthly rent?
Current apartment/home size (if applicable)
Including yourself, how many people are in your household? *
Include spouse, partner, children, etc.
Over the last 3 years, how long have you been without housing? (if applicable)
Do you have any physical and/or mental health conditions?
Are you completing this form for yourself? Or on someone's behalf? *
If you are completing this form on someone else's behalf, please list your contact information here (name, phone, email).
Should be Empty:

Client Referral Assessment