Client Intake Forms
Welcome to Online Client Intake.

Please complete Online Client Intake. 
You will be placed in queue and we will call you back in the order received. 
This will help to streamline the process and provide you resources in a timely manner. 

We provide resources and referrals of help to Medina County Residents!

Completing this online form will help us to respond to you faster. Thank you in advance for your thorough completion. We know a lot of information is required. It is all necessary to our ability to accurately assess your needs. We verify all information provided. Examples of assistance that may be proved: *Rent *utilities * car repairs *furniture Assistance is not provided for: *Security deposits *first months rent *mortgage payments *hotel or room rentals *car payments or insurance *daycare *storage units *home health *prescriptions. If you would like resources to other agencies, we are able to provide them. Please fill out the form with these guidelines in mind.


This is a must read!

If you are currently dual eligible, with both Medicare and Medicaid there may be more benefits available to you! 
Stating at NEARLY 0 dollars cost. 


Click the logo below to receive more information and signup information!