Community Connections Intake Questionnaire

Welcome to the Community Connections Program at LA Law Library! This program is designed to provide you general information, resources and referrals to public agencies or social service providers in our community.

* indicates required information. All of your information will be treated as confidential.

Name Name First Last
Media
Age
Preferred Language
Preferred Pronouns

Preferred Pronouns she/her him/his they/them
Preferred method of contact:

Preferred method of contact: Phone # Alternative # Email
Please provide Phone/Alternative/Email:
How did you hear about Community Connections/LA Law Library?
Services you are seeking:

Services you are seeking: Housing Health Care Assistance Assistance Finding Employment Food Substance Abuse Veteran Services Clothing Elder Care Mental Health Services Other Other
How can we help? What questions do you have about this service?
What other information can you provide that would be help us assist you?
Where are you located? If there is a choice, what is your preferred area or location for
accessing services?
What have you tried? Who have you called?
For follow up assistance, what days of the week work best for you? Do you prefer morning or afternoon? *
Are there deadlines you know of or other circumstances that make this urgent?
CONSENT

I knowingly and freely share my information with a Community Resource Specialist and assume full responsibility for my participation in the Neighborhood Connections program. I willingly agree to comply with the Rules of Conduct of LA Law Library and any regulations of this program.

By signing below, I consent to my story being used anonymously (i.e., without my name) by LA Law Library to conduct outreach about the Library and promote the Community Connections program.

I have read this Disclosure or have had it read to me. I understand this document and hereby release LA Law Library and its employees or agents from any claim, liability or damages arising out of or in connection with receiving information or assistance under this program.

LA Law Library is not responsible for the content or quality of any information or advice you may receive from the agencies or organizations to which you are referred.
Name Name First Last
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Full Name

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Date Date / MM / DD YYYY
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Community Connections Intake Questionnaire

Community Connections Intake Questionnaire

Media

CONSENT