Welcome Reception Form

Thank you for contacting PorchLight. Your safety and privacy are our top priorities. To better assist you, please provide the following information. All information provided on this form will be stored in a confidential database, accessible only to authorized personnel and protected in accordance with our confidentiality policy. Upon submitting this information, we will contact you in the method indicated below. You may also walk into PorchLight during our hours. If you have questions or concerns, please reach out at (720) 853-8850 or email hope@porchlightfjc.org.

GUEST INFORMATION

First name

Last name

Gender

Pronouns

Select the pronouns you use.

Birthday

Month

Day

Year

Email

Phone

Address

City/State

Zip Code

County

Race/Ethnicity

Preferred Language

Is it safe to contact you? (Please note PorchLight calls will typically come from a private or unlisted number).

Yes

No

If yes, best time to contact?

Preferred method of contact

Phone

Email

Do you have Medicaid coverage?

Yes

No

EMERGENCY CONTACT INFORMAITON

Emergency Contact

Emergency Contact Phone/Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Relationship to You

Is this person in your home?

Yes

No

SUPPORT INFORMATION

How did you hear about PorchLight?

Do you have disability that you would like us to be aware of so that we can better support you?

PERSON CAUSING HARM

First Name

Last Name

Date of Birth

Gender

Race/Ethnicity

HOPE ASSESSMENT

Read each item carefully. Using the scales below, rate each statement that best describes YOU.

I can think of many ways to get out of a jam.

I energetically pursue my goals.

I feel tired most of the time.

There are lots of ways around any problem.

I give up easily in an argument.

I can think of many ways to get the things in life that are important to me.

I worry about my health.

Even when others get discouraged, I know I can find a way to solve the problem.

My past experiences have prepared me well for the future.

I have been pretty successful in my life.

I usually find myself worrying about something.

I meet the goals I set for myself.

SUBMISSION INFORMATION

Date and time

Month

Day

Year

Time

HoursMinutes

I am submitting this information

For myself

On behalf of someone else (fill below)

Other

If you're assisting someone else with this form, please provide your name, agency, and contact info here.

Is there anything else you'd like to share with us? (Optional)

Please add any additional details that may be helpful for PorchLight Navigators to know.

Signature

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Signing here indicates this information is true and accurate to the best of your ability. Additionally, by signing you give PorchLight permission to contact you for follow-up.