Information & Assistance Referral Form

Please note: Client must be a resident living in region 1A (Detroit, Hamtramck, Highland Park, Harper Woods and the five Grosse Pointes).
(two or more of the following should have checks)
(home delivered meals)
I affirm that the information is accurate to the best of my knowledge.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.