Skip to content

About
- Our Story
- Leadership
- Careers
- Contact
Our Work
- Programs
Insights
- News
Events
Get Involved

About
- Our Story
- Leadership
- Careers
- Contact
Our Work
- Programs
Insights
- News
Events
Get Involved

June 27, 2023

JBJ Soul Homes building exterior during the day

ANNUAL REPORT 2021-2022

June 27, 2023

Stay Connected.

HELP USA Intranet
Privacy Policy
Press Information

HELP USA Intranet
Privacy Policy
Press Information

X-twitter Facebook Instagram Linkedin-in

115 East 13th Street New York, NY 10003 | Phone: 212-400-7000

© 2024 HELP USA. HELP USA is a 501(c)3 tax-exempt organization. EIN 13-3770118.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

About
- Our Story
- Leadership
- Careers
- Contact
Our Work
- Programs
Insights
- News
Events
Get Involved

X-twitter Facebook Instagram Linkedin-in

Stay Connected.

First Name

Last Name

Email

Self-Referral Form

Preferred Name

Gender Identity

Contact Number

Contact Email

Safe Times to Call

Type of Service Requested:

In-Person Services Virtual Services

Services Requested:

Home+ Services Parenting Journey OVS Application/Information Individual Counseling Group Counseling Family Order of Protection Filing Children's Program (Counseling)

Are you attending any additional services?

Yes No

What services?

Case Management Therapy Medication Management Other

Why are you seeking services?

Client Referral for Services

Referral Information

Today’s Date

Name

Agency’s Name

Agency Phone

Referral Source/Agency Email

Client Information

Client Name

Gender Identity

Address

Zip Code

Phone

Email

Date of Birth

Language

Special Calling Instructions

Family Composition (excluding client, please list ALL children under 18yrs of age):

In Foster Care

In Foster Care

In Foster Care

In Foster Care

Reason for Referral or Presenting Problem

Type of Service Requested:

In-Person Services Virtual Services

Services Requested:

Home+ Services Parenting Journey OVS Application/Information Individual Counseling Group Counseling Family Order of Protection Filing Children's Program (Counseling)

Is client attending any additional services?

Yes No

What services?

Case Management Therapy Medication Management Other

Has client provided verbal/written consent to be contacted by HELP R.O.A.D.S?

Yes No

Photo Inquiry

First Name

Last Name

Email Address

Phone Number

Organization Name

Message