Please provide the following information to help us serve you better:

In what city within our service area is this help needed?

If you live in areas in or near Bisbee, Clifton, Nogales, Safford, Sierra Vista, or Tucson, please contact Information & Referral Services in Tucson for assistance.

Your Email Address:

Please note that characters such as "_" (underscore) in your email address may cause this form to not work. If that happens, please call us for assistance at 602-263-8856 from anywhere or 800-352-3792 within area codes 520 & 928.

Confirm Email Address:

What is your Zip Code?

How long have you lived at your current residence? --Please select from list-- 0-5 months 6-10 months 11-15 months 16-20 months 21-30 months 31-59 months 60+ months Refuse to Answer

What is your age group? --Please select from list-- 0-13 years 14-17 years 18-30 years 31-59 years 60-64 years 65-74 years 75+ years Refuse to Answer

What is your gender? --Please select from list-- Male Female

What is your ethnic background? --Please select from list-- African-American Asian/Pacific Islander Caucasian Hispanic Native American Other Refuse to Answer

Please briefly describe the kind of assistance you need:

Please note that will be referring you to people who may help you. We do not give advice on issues including, but not limited to, legal, medical, landlord-tenant, nor do we offer direct services for case management, counseling, food, or shelter.

Do not send us any sensitive information including Social Security numbers, legal case numbers or specific court case histories. Court cases must be handled by you or your legal counsel with the court in which they were or are to be tried.

How did you hear about us? --Please select from list-- Brochure/Flyer CIR Directory Newspaper Personal Referral Professional Referral Search Engine Surfing the Web Telephone Directory TV/Radio News Other Website Link

For faster help call our 24-Hour Help Hotline
602-263-8856 from anywhere
800-352-3792 within area codes 520 & 928
Callers using TDD, please use Arizona Relay (800-367-8939 or 7-1-1)
Or use our Online Directory of Human Services

If this form does not work for you, call us.