Please enable JavaScript in your browser to complete this form.Personal Information - Step 1 of 7Name *FirstLastPhone *Email *Preferred Language *Haitian CreoleEnglishFrenchSpanishHow they want to be contacted *CallText MessageWhatsAppEmailNextAddress *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCan You Travel to Receive Services? *I can travel to receive servicesI need services to come to mePreviousNextNumber of Adults in Household *Number of Children in Household *Do you have U.S. Citizen Children? *YesNoCurrent Employment Status *Full-TimePart-TimeSelf-EmployedUnemployedUnable to WorkOtherPreviousNextTPS Status *Active TPS HolderTPS Application PendingFamily Member of TPS HolderOtherOther Legal Status (if applicable)Do You Currently Have an Attorney? *YesNoPreviousNextSelect All Services Needed *Legal ConsultationKnow Your Rights WorkshopApplication Filing AssistanceFamily Emergency PlanFood AssistanceHome Delivery ServicesMental Health SupportPeer Support CircleEmployment AssistanceSNAP / WIC Benefits AssistanceTransportation SupportHousing AssistanceHealthcare Access SupportChildren & Families SupportOtherIf Other, Please Specify⚠ This is an urgent or emergency situationI am in immediate danger, detention risk, or facing imminent deportation and need urgent assistance.PreviousNextTell Us About Your Situation *Important Deadline *Best Time To Contact You *MorningAfternoonEveningAnytimePreviousNextI understand this form is confidential. My information will only be used to connect me with services through RL Bethany Relief Services INC and will not be shared with government agencies, ICE, or any third party without my written consent.I agree to be contacted by RL Bethany Relief Services INC via my preferred contact method to discuss my request and connect me with services.Your Safety: RL Bethany Relief Services INC will never report you to immigration authorities or share your information with any government agency. Our services are 100% confidential and provided with your safety as our first priority. Submit Need Help Right Now? CALL OR TEXT (908) 209-8738 EMAIL info@rlbethanyrs.org Mon – Sat | Haitian Creole & English All services are free and confidential. What Happens Next 1 We receive your request and review your needs within hours 2 A team member contacts you within 24 hours via your preferred method 3 We connect you with the right services — legal, food, mental health, and more 4 We follow up with you to make sure everything is in place Languages We Serve In We receive your request and review your needs within hours 🇭🇹 Kreyòl Ayisyen 🇺🇸 English 🇫🇷 Français 🇪🇸 Español Emergency Resources We receive your request and review your needs within hours 1-888-576-5529 Legal Services of NJ — Free 988 Mental Health Crisis Lifeline info@rlbethanyrs.org Family Emergency Plan
