About Catholic Charities of Central Florida provides free healthcare services—including medical, dental, case management, and preventative education—to individuals and families in critical need. These needs are met by dedicated healthcare professionals, many who volunteer, in Behavioral Health Services, Medical & Dental Clinics, Pathways to Care, and Senior Wellness Services. To help with healthcare as a volunteer, please click here. To request assistance and to expedite your first appointment, please complete the intake form below. Ministries Behavioral Health ServicesMedical & Dental ClinicsPathways to CareSenior Wellness Services Catholic Charities of Central Florida Intake Form Who are you?This information is only used by our team and will not be shared with any other entity unless required.Birth Date(Required) MM slash DD slash YYYY Primary Language Spoken(Required)EnglishHaitian CreoleSpanishOtherLanguage: Other(Required) Name(Required) First Last Preferred Contact Method(s)(Required)Select all that apply. Email Phone Text PhoneEmail County(Required)Choose OneBrevardLakeMarionOrangeOsceolaPolkSumterSeminoleVolusiaOtherCounty: Other(Required) Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How can we help you?By completing this section, it will help us get your file to the proper ministry to help serve you.Services Needed(Required) Financial Assistance Food Assistance Healthcare Housing Human Dignity Immigrants & Refugees Services Needed: Healthcare(Required) Behavioral Health Services Medical & Dental Clinics Senior Wellness Services Services Needed: Human Dignity(Required) Culture of Life Human Trafficking Task Force Services Needed: Immigrants & Refugees(Required) Comprehensive Refugee Services Immigration Legal Services Have you been financially impacted by the COVID-19 pandemic?To be eligible for pandemic-related assistance, proof will be required for anything checked below. Assistance for those not specifically impacted by the pandemic is also available. No Yes - I lost my job. Yes - Someone in my household lost their job. Yes - I maintained my job, but my income was reduced. Yes - I am behind on my rent by at least one month. Yes - Other (Please explain in the comments section below) Comments(Required)How can we help you?Consent(Required)I agree that the data I provided may be used for the purpose securing services and stored for Catholic Charities of Central Florida's inventory records and to evaluate interest in Catholic Charities of Central Florida's web pages. I further agree to receive email communications about Catholic Charities of Central Florida's goods, services, and information. I agreePhoneThis field is for validation purposes and should be left unchanged.