Request for Services

Please complete the form below

Please note if you are being evicted, we do not take on eviction cases. Contact the Tenancy Preservation Program at 508-944-9502 or 508-208-5906. Please note we also do not provide emergency housing. If in Bristol County and have a 508 or 774 area code please call 1-800-HOMELESS. Families should contact the Remote Access Line of DHCD (Dept. of Housing and Community Development) at 866-584-0653.

Name *
Name
Birthday
Birthday
Have you received services from SCIL before?
Are you able to get to the SCIL office for your appointment? *
If not able to get to SCIL is your home accessible?
Are you in school? *
Address
Address
Phone
Phone
Cell
Cell
Alternate Phone Number
Alternate Phone Number
What form of communication are you most comfortable with?
Do you have an email you check regularly?
Do you have any pets?
If yes, please specify:
Do you have a substance abuse/alcohol problem?
Please select the service(s) you are requesting:
Are you receiving other service(s)?
Referred by:
What sources of income do you have?
What type of health insurance do you have?