Confidential intake

Tell us what's needed tonight.

Pick the tracks that fit — veteran, DV survivor, HIV/AIDS, youth / foster alumni, or returning citizen. The shared details fill in once; each track adds a short, conditional section. Same-day triage where the funder permits.

Outreach partners can fill this out on a resident's behalf at the bedside or in the van — switch that on near the bottom of the form.

In an immediate safety crisis, call 911 or the Baltimore City Crisis Response line. This form is monitored during business hours.

Step 1 · Tracks

Which tracks apply to this resident?

Multi-select. Each track unlocks a short, conditional details card below.

Tracks

Step 2 · About the resident

Required for the typed signature.

Check if it's checked by no one the resident is fleeing. Leave blank to flag the row for staff.

Emergency contactSomeone safe who is not currently with the resident.
Income sourcesPick any that apply. Leave blank if you prefer not to say.
$
Current benefitsPick any that apply.

We only ask for general recency — never details.

We'll ask for your name and organization below.

0 / 2000

Stored with the intake. Not included in staff notification email.

Step 4 · Documents

Optional. ID, discharge papers, proof of income, or anything else. Files are encrypted in transit; we never share them.

  • No file selected
  • No file selected
  • No file selected

Accepted: image, PDF, Word, PowerPoint, Excel, text, CSV (max 50 MB each). Files travel encrypted and live in a private R2 bucket keyed to this organization. Submitting without docs is fine — staff will follow up.

Step 5 · Consent

By typing your full legal name below, you consent to receive services from WE STRIVE and authorize release of information to assigned case workers only.

Required to submit. Withdrawing consent doesn't delete earlier intake records.