Pelagie Care Client Intake

Apply for Services

Complete this secure form to request support from the Pelagie Foundation. A member portal account will be created so you can track your journey with us.

Need help? Call (470) 356-6285

Your Account

Create login credentials for the member portal

Full Name *

Email *

Password *

Confirm Password *

Personal Information

Phone

Date of Birth *

Gender

Household Size

Street Address

City

State

ZIP

Program & Needs

Program of Interest

How did you hear about us?

What do you need help with?

Income & Housing

Income Level

Monthly Income *

$/mo

Employment Status

Housing Status

Veteran / Active Military

I receive SNAP (food assistance)

Emergency Contact

Name

Phone

Additional Notes

Tell us anything else that would help us support you

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