Client Intake Form

Thank you for contacting Central Illinois Resource Center Inc. (CIRC). This form helps our team better understand your needs and connect you with available support, information, and community resources.

Please complete this form as accurately as possible. Submission of this form does not guarantee services, placement, financial assistance, or emergency intervention.

Important:
CIRC is not a crisis response agency, emergency shelter, law firm, medical provider, or government agency.
If you are in immediate danger or experiencing a mental health emergency, call 911 or 988 immediately.

Central Illinois Resource Center Inc. (CIRC) provides community support, peer support, advocacy, and referral information. Completion of this form does not establish a counselor-client, attorney-client, medical provider-patient, or emergency services relationship. CIRC reserves the right to decline services, limit communication, or refer individuals to outside agencies when appropriate.