Begin Your Journey Toward Stability & Healing

Complete the confidential intake form below so we can better understand your needs and connect you with the appropriate support, housing resources, wellness services, or recovery guidance.

Trauma-Informed Support
Confidential Intake Process
Serving Fort Wayne & Surrounding Communities

Tell us about yourself

First name*

Last name

Phone*

Email*

Birthday

Month

Day

Year

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

What Support Are You Seeking?

Select all areas where you are currently seeking support.*

Transitional Housing

Recovery Support

Peer Recovery Coaching

Reentry Support

Veteran Support Services

Wellness Experiences

Breathwork & Sound Healing

Community Resources

Employment/Life Skills Support

General Guidance

Current Situation

This information helps us better understand how we may be able to support you.

Housing Situation*

Are You Currently In Recovery?*

Yes

Prefer Not to Say

Veteran Status

Yes

Are You Currently Employed?*

Full-Time

Part-Time

Unemployed

Seeking Employment

Prefer Not To Say

Transportation Access

Reliable Transportation

Limited Transportation

No Transportation

Your Goals & Your Story

Share a little about what you’re hoping to achieve and how we may be able to support your journey.*

How Did You Hear About Us?*

Consent & Confidentiality

I understand that submitting this form does not guarantee placement or services, but allows Emergent W.O.R.T.H. to review my information for follow-up support.

I consent to being contacted regarding available services and resources.

You are not alone. You have taken a big step and we want to take the next steps with you.

Thank you for taking the time to complete this intake form. A member of the Emergent W.O.R.T.H. team will review your information and follow up as soon as possible.

Home
About
Apply for Help

bottom of page