RW Client Interest Form
This is not an emergency housing program. If you do not currently have a place to stay or if you are in danger of losing your housing, please contact the Housing Crisis Line: 804-422-5061
Please complete this form to request RW services at Health Brigade
Once you complete this form someone will reach out to you using the information you provide below within 2 business days to schedule your appointment. Please keep in mind we are closed Satudays & Sundays and most major holidays.
Full Name
*
First Name
Last Name
First choice method of contact
*
Phone call
Email
Second Choice method of contact
Phone call
Email
N/A
1. Phone Number
*
-
Area Code
Phone Number
1. Email
*
example@example.com
2. Phone Number
*
-
Area Code
Phone Number
2. Email
*
example@example.com
Services I am interested in
*
Goal setting, ongoing case management
Food vouchers
Transportation assistance
One time financial assistance
Submit
Should be Empty: