Lucie's Place · I need help

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I need help

If you are a homeless LGBT young adult (18-25), please fill out this form to the best of your ability. A staff member of Lucie's Place will contact you as soon as possible to arrange a meeting and begin working with you. Please provide as much information as possible about you, your situation and what sort of help you need.

Name you go by

First Name

Last Name

Legal name

First Name

Last Name

What is your phone number?

Can we call you at this number?

Yes, I will answer

Yes, but someone else will answer

No, do not call this number

What name should we use for you when calling this number?

What pronoun (he, she, they, etc.) should we use for you when calling this number?

What city are you currently staying?

What city and state were you born?

How old are you?

Tell us about your relationship with your family

I understand

Please check each box, showing that you understand and agree

I am LGBTQ identified and between the ages of 18-25

Yes

I understand that filling out this form does not guarantee Lucie's Place will be able to assist me

Yes

All the information on this form is true, as far as I know

Yes