Love INC Assistance Request Form

We at Gallatin County Love In the Name of Christ know that asking for help can be hard. We want you to know we don't judge you or your situation. We want to help in any area we are able to.

We are a call center, which means we do all client intake and volunteer matching over the phone. But you can get a jump start on the process by filling out some basic information on this form.

Love INC serves residents of Gallatin County. We are not an emergency service. We believe in taking time to hear your story and help you come up with solutions. Part of the Love INC process is the verification of information shared. When contacted by Love INC, please be prepared to engage in the process.

Once Love INC receives this initial form, a volunteer will contact you by phone to complete your request. Due to our high volume of requests it may take some time for one of our volunteers to reach out to you. If you haven't heard back, please feel free to contact us again. Our phone number is (406) 587-3008, then select option 2 for the Connection Center.

Form submissions are sent over an SSL encrypted connection.

Date

First Name

Middle Name

Last Name

Phone Number

Please provide your primary phone number that we can use to contact you.

Is this a mobile number?

YesNo

If yes, who is your cellular provider?

If we can not reach you by phone, we may try to text you through a computer texting program in which we would need your cellular provider.

Email

Date of Birth

Secondary Phone

Please provide a secondary phone number if your primary phone number is not reliable.

Who lives in your household? Please provide names, relationships, and birth dates.

EXAMPLE: I live with John Doe, my husband, 2/5/1964 and Jane Doe, my daughter, 11/14/2008.

Physical Address

Address Line 1

City

State/Province

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

Postal Code

Are you a resident of Gallatin County?

YesNoNOTE: Love INC services are limited to residents of Gallatin County. If you live outside the county, we may be able to brainstorm options and referrals with you, but we won't be able to activate any of our volunteers to help meet your need(s).

Have you ever contacted Love INC before?

YesNo

If you are a new client, how did you hear about Love INC?

Assistance Requested

Please indicate what you are seeking assistance for. There are no guarantees Love INC will be able to assist with your request(s), but we will listen, problem solve with you, and do our best to come up with an appropriate solution.

Almost Done!
The information provided in the following questions allows Love INC to better assist you with your request(s).

What transportation is available to you? (If applicable, select more than one option.)

I get rides from familyI get rides from friendsI have a vehicleI ride public transportationOtherIf approved, some Love INC assistance will require you to travel to an appointment within our Partner Church Network.

Please explain.

What is your housing situation?

I am homelessI ownI rentI stay with someone

What is your employment situation? (Check all that apply)

I am disabledI am employed part timeI am employed full timeI am retiredI am unemployed and not seeking a jobI am unemployed and am seeking a job

What is your estimated monthly income and from what source?

EXAMPLE: $1200 from working at Smiths, $800 from disability)

Once Love INC receives this initial form, a volunteer will contact you by phone to begin working on your request.

Please keep in mind that we are run by volunteers. Due to our high volume of requests, it may take some time for one of our volunteers to reach out to you.

If you haven't heard back, please feel free to contact us again. Call (406) 587-3008 and select option 2.

By checking the box below, you understand:

• We are not a crisis center. If you are in crisis, call 211 or 911.
• We are run by volunteers. Please be kind and patient.
• We will try to contact you two times. If we can not reach you, we will archive your request for assistance.
• You should call us if you don't hear back in a week or two.

I understand the above