September 12, 2026

Client Case Assistance & Advocacy Center This is our form for any Assistance Please Fill out if you Need Assistance in Florida Mississippi Alabama Pennsylvania

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Client Case Assistance — Mississippi, Alabama, Florida & Pennsylvania

Request Assistance. We’ll Be There to Help.

Professional case support, resource coordination, documentation assistance, and client advocacy services are available across Mississippi, Alabama, Florida, and Pennsylvania.

Whether you need help organizing a case, preparing documentation, identifying resources, or determining the next steps, our team is here to help you navigate the process.

Submit a Request for Assistance Today

Referral and Case Summary Only: Heaven-Sent Community Services & Veterans Assistance uses this form to collect information the client voluntarily provides so staff can make referrals and help the receiving SSVF, VA, HUD-VASH, or housing provider begin its own intake. This form does not determine eligibility, enroll a participant, approve financial assistance, issue a housing voucher, or replace the receiving program’s required forms, privacy notices, releases, or verification process.

Client Intake & Casework Form | Heaven-Sent Community Services
Heaven-Sent Community Services & Veterans Assistance

Client Intake & Casework Form

Comprehensive intake, crisis assessment, client consent, document tracking, referral coordination, release of information, and follow-up in one form.

Confidential casework worksheet. This form supports intake and case management. It does not guarantee eligibility, financial assistance, benefits, housing, VA enrollment, FEMA assistance, or any referral outcome. Do not enter Social Security numbers, VA file numbers, bank-account numbers, medical records, or other sensitive documents here or send them through ordinary email. Use approved secure procedures for sensitive records.

Part 1 — Client Intake

1Identity, Contact & Case Number
Generated locally; verify against agency records.
2Client Type, Household & Support Needs
NameRelationshipDate of BirthVeteran?Disabled?Needs Assistance?
3Veterans-Specific Intake

Part 2 — Case Assessment & Services

4Program Areas, Crisis & Assessment
5Documents, Referrals & Internal Tracking

Part 3 — Client Consent & Release of Information

6Client Consent

HMIS is the local Continuum of Care’s Homeless Management Information System. If Heaven-Sent participates in HMIS, use the local CoC’s approved privacy notice and consent/refusal process. This intake form does not replace that local process.

7Consent to Talk / Release of Information
Important: A Release of Information is voluntary and should be used only when the client authorizes Heaven-Sent to speak with a specific person or organization. It does not replace specialized VA, medical, behavioral-health, substance-use-disorder, HMIS, or other required authorizations.

Limited authorization. I authorize Heaven-Sent to communicate with the person(s) or organization(s) identified below only for the purpose(s) I select. Heaven-Sent may request, receive, and disclose only the minimum information reasonably necessary.

Voluntary and revocable. I may refuse to sign or may revoke this authorization in writing at any time, except to the extent Heaven-Sent or another party has already acted in reliance on it.

Separate specialized releases may be required. Heaven-Sent will use the applicable approved form before requesting or disclosing specially protected information.

Part 4 — Signature, Staff Review & Follow-Up

8Participant Attestation & Staff Follow-Up
Draft privacy warning: Saved drafts are stored only in this browser on this device and are not encrypted. They are not a secure case file. Use them only if Heaven-Sent policy permits it.

Email summary is addressed to Tim with Joe copied. Use only approved secure procedures for sensitive records and attachments.