DISASTER CASE MANAGEMENT (DCM)Intake and Self-Assessment Form

DISASTER CASE MANAGEMENT (DCM)
Intake and Self-Assessment Form

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READ BEFORE YOU START

1. Clients (Adult) may only submit one application per household: This intake is intended for new clients to the North Carolina Disaster Case Management (DCM) Program. The form must be completed by an adult household member. If you have previously applied to the DCM Program, please call (844) 746-2326 for the status of your current application and next steps.

2. Online application guidance: An email address will be required in order to submit a complete application. As you are completing the application, please do not hit the back or refresh button on your internet browser, as information may be lost.

3. Completing the application: The intake application is the first part of the NC DCM Program process.

4. Need help completing the online application: Please do not hesitate to call (844) 746-2326 to speak with a program representative if assistance completing the application is needed.

5. Saving the application: You may choose to save the application to complete and submit later. When you click the Save button, you will be prompted to enter an email address and password. You will receive an email confirmation that the response was saved including a link for returning to your online application. Emails from the online application platform may fall into your spam folder so please be sure to monitor all folders in your email. If the email does not appear in your inbox or spam folder, please do not start another application. Contact us at (844) 746-2326 to confirm your email address and access your application.

6. Resume saved application: You may resume a saved application at any time prior to completing and submitting the application. You will need the email address and password that you provided when you saved the application.

7. After submitting the application: A case manager will reach out to you to discuss next steps and request any additional supporting documentation that may be needed to move forward. You may also call (844) 746-2326 for additional information.

VERIFICATION YOU HAVE NOT COMPLETED A PREVIOUS APPLICATION

If you have already submitted a DCM application, do not submit another application. If you need to update your previous application for any reason, you may do so when your case manager reaches out to you. Duplicate applications are marked as duplicates and are not considered eligible for the program.

RECOVERY PROGRAM ACKNOWLEDGMENT

I understand that a case manager will help me learn about resources that are already available to me, and I will work on getting help for myself.

RELEASE OF INFORMATION

By completing this DCM application, I understand that my personal and household information may be shared with agencies, entities, and local partners, as necessary, to support my recovery from Tropical Storm Helene.

You must answer all of the following questions.

1. Were you a resident of the state of North Carolina when Tropical Storm Helene impacted NC on September 27, 2024?

Yes

2. In which North Carolina county did you live or work in when Tropical Storm Helene impacted NC on September 27, 2024?

3. Does your household have Helene-related unmet needs?

Yes

4. The Adult Client or Primary Applicant must complete this application. Are you the Adult Client/Primary Applicant?

Yes

Thank you for your interest in the North Carolina Disaster Case Management (DCM) Program.

Your responses have been submitted. Based on the information provided, your application is not eligible for assistance. If you have questions, please call (844) 746-2326.

You cannot apply for assistance based on the following criteria:

You were not a resident when Tropical Storm Helene impacted NC.

Your household does not have Helene-related unmet needs.

You are not the Adult Client/Primary Applicant.

The county in which you live is not in a Tropical Storm Helene impacted county.

Click X on your web browser to exit the DCM Intake application.

CLIENT INFORMATION

The CLIENT must be an adult representing the household. Please do not enter a minor as the CLIENT.

First Name

Middle Name

Last Name

Alias/Preferred Name

Date of Birth (MM/DD/YYYY)

Gender

What is the best phone number to contact you?

Is the contact number a mobile phone?

Yes

Current Alternate Phone #

Client Email Address

BEST CONTACT INFORMATION

What is the best time of day to contact you?

Anytime	8:00 AM – 9:00 AM	9:00 AM - 10:00 AM
10:00 AM – 11:00 AM	11:00 AM – 12:00 PM	12:00 PM – 1:00 PM
1:00 PM – 2:00 PM	2:00 PM – 3:00 PM	3:00 PM – 4:00 PM
4:00 PM – 5:00 PM

Preferred Language

EnglishSpanishOther:

Enter other preferred language

EASTERN BAND OF CHEROKEE INDIANS of NC

Are you or anyone in your household a citizen of the Eastern Band of Cherokee Indians?

Yes

COMMUNICATION DESIGNEE

A communication designee is a person who can speak for you, get information, and answer basic questions about your application but not make decisions or sign documents on your behalf.

Do you have a communication designee?

YesNo

First Name

Middle Name

Last Name

Phone #

Email Address

COMMUNICATION METHOD

Do you or another member of your household use translation or interpretation services?

Yes

Do you or another member of your household regularly use communication devices or methods to help, see, understand, or communicate better?

Yes

Select all communication devices or method to used to help, see, understand, or communicate better?

American Sign Language (ASL) InterpreterBlind SupportBrailleCap Tel PhonesCART (Communication Access Real-Time Translation)Deaf SupportHearing AidsHearing Aid BatteriesRelay ServicesScanning SystemScreen MagnificationScreen ReadersService or Support AnimalTactile GraphicsVision AssistanceOther:

Describe your other communication devices or methods.

VETERAN

Have you or any member of your household served or are currently serving in the United States Armed Services? (Air Force, Army, Marine Corps, Navy, Coast Guard, National Guard, Reserves)

YesNo

FEMA REGISTRTATION

Did you register with FEMA?

YesNo

FEMA Registration #

PETS/LIVESTOCK

Do you have any Pets or Livestock?

PetsLivestock

Please describe your pet/livestock situation (for example: 2 dogs, 25 cows, 3 chickens).

OTHER HOUSEHOLD OCCUPANT INFORMATION

Current Household Size (including Client/ Primary Applicant)?

HOUSEHOLD OCCUPANT #2 INFORMATION (Full Legal Name)

First Name

Middle Name

Last Name

Relationship to Applicant?

Describe other relationship:

Is this household member a Dependent?

Date of Birth (MM/DD/YYYY)

Gender

Enter Co-Applicant Contact Information

Co-Applicant Phone #

Is the contact number a mobile phone?

Yes

Co-Applicant Alternate Phone #

Co-Applicant Email Address

HOUSEHOLD OCCUPANT #3 INFORMATION (Full Legal Name)

First Name

Middle Name

Last Name

Relationship to Applicant?

Describe other relationship:

Is this household member a Dependent?

Date of Birth (MM/DD/YYYY)

Gender

Enter Co-Applicant Contact Information

Co-Applicant Phone #

Is the contact number a mobile phone?

Yes

Co-Applicant Alternate Phone #

Co-Applicant Email Address

HOUSEHOLD OCCUPANT #4 INFORMATION (Full Legal Name)

First Name

Middle Name

Last Name

Relationship to Applicant?

Describe other relationship:

Is this household member a Dependent?

Date of Birth (MM/DD/YYYY)

Gender

Enter Co-Applicant Contact Information

Co-Applicant Phone #

Is the contact number a mobile phone?

Yes

Co-Applicant Alternate Phone #

Co-Applicant Email Address

HOUSEHOLD OCCUPANT #5 INFORMATION (Full Legal Name)

First Name

Middle Name

Last Name

Relationship to Applicant?

Describe other relationship:

Is this household member a Dependent?

Date of Birth (MM/DD/YYYY)

Gender

Enter Co-Applicant Contact Information

Co-Applicant Phone #

Is the contact number a mobile phone?

Yes

Co-Applicant Alternate Phone #

Co-Applicant Email Address

HOUSEHOLD OCCUPANT #6 INFORMATION (Full Legal Name)

First Name

Middle Name

Last N

Relationship to Applicant?

Describe other relationship:

Is this household member a Dependent?

Date of Birth (MM/DD/YYYY)

Gender

Enter Co-Applicant Contact Information

Co-Applicant Phone #

Is the contact number a mobile phone?

Yes

Co-Applicant Alternate Phone #

Co-Applicant Email Address

HOUSEHOLD OCCUPANT #7 INFORMATION (Full Legal Name)

First Name

Middle Name

Last Name

Relationship to Applicant?

Describe other relationship:

Is this household member a Dependent?

Date of Birth (MM/DD/YYYY)

Gender

Enter Co-Applicant Contact Information

Co-Applicant Phone #

Is the contact number a mobile phone?

Yes

Co-Applicant Alternate Phone #

Co-Applicant Email Address

HOUSEHOLD OCCUPANT #8 INFORMATION (Full Legal Name)

First Name

Middle Name

Last Name

Relationship to Applicant?

Describe other relationship:

Is this household member a Dependent?

Date of Birth (MM/DD/YYYY)

Gender

Enter Co-Applicant Contact Information

Co-Applicant Phone #

Is the contact number a mobile phone?

Yes

Co-Applicant Alternate Phone #

Co-Applicant Email Address

LIVING SITUATION AT THE TIME OF TROPICAL STORM HELENE'S IMPACT

Which describes your living situation at the time of Tropical Storm Helene's impact?

Apartment/ Condo	Single Family Home	Multi-Family Home	Mobile Home
Recreational Vehicle (RV)	Hotel/ Motel	Homeless	Shelter
Tent	Vehicle	Other:

Describe your other living situation.

Which describes your storm impacted property type?

Homeowner

Rental

Subsidized Housing (Section 8, HUD, etc.)

How would you categorize your storm impacted residence?

My primary residence was not damaged.AFFECTED: Residence with minimal damage to exterior and/ or contents of home.MINOR: Wide range of damage that does not affect the structural integrity of home.MAJOR: Sustained significant structured damage and requires extensive repair.DESTROYED: The residence is a total loss or damage is too much to be repaired.

STORM IMPACTED ADDRESS INFORMATION

Number of individuals in the primary residence, including the Client/ Primary Applicant?

Storm Impacted Address Line 1

Storm Impacted Address Line 2

Describe location, cross streets or other information, if applicable.

City

State

5 digit Zip code

Are you able to return home?

YesNo

If yes, date of return: Date (MM/DD/YYYY)

What is preventing you from returning home?

CURRENT LIVING SITUATION

What best describes your current housing type/situation?

Apartment/ Condo	Single Family	Multi-Family	Mobile Home
Recreational Vehicle (RV)	Hotel/ Motel	FEMA Trailer	Homeless
Shelter	Tent	Vehicle	Other:

Describe your other current housing situation.

Is your current address the same as your storm-impacted address?

Yes

CURRENT HOUSING ADDRESS

Describe location, cross streets or other information, if applicable.

Current Address Line 1

Current Address Line 2

City

State

5-Digit Zip code

Is location status long term?

YesNo

Start Date (MM/DD/YYYY)

End Date (MM/DD/YYYY)

Where will you go if you cannot stay at the current address?

SELF-REPORTED DISABILITY/AT-RISK POPULATION

Are you or anyone in your household a Special/At-Risk Population? For example: children, elderly, disabled, limited English proficiency, illiterate, homeless, etc.:

Yes

Self-Reported Special/At-Risk Populations, select all that apply:

Children Elderly Individuals with disabilities in the household Individuals with limited English proficiency Literacy challengesSevere mental trauma, physical limitations, or a member of the functional needs community in the householdShelter/Homeless Other:

Describe your other at-risk situation(s) not captured above.

SELF-IDENTIFIED DISASTER-CAUSED UNMET NEEDS

Self-identified disaster-caused unmet need(s). Include those that apply. For example:

Assistance locating a person or family missing due to the disasterAssistance with accommodating or caring for a domesticated animal or petAssistance with temporary storage of household itemsBehavioral health access, crisis counseling, or spiritual and emotional careEmploymentEssential clothingEssential furniture and/or appliancesFEMA assistance (registration or appeals)Financial assistanceFood and type (e.g. baby food)Functional needs assistance with services, devices, and modificationsFuneral cost assistance (e.g. memorial, transportation, disposition of remains)Health insurance or healthcare accessHousing assistance (temporary, interim, to long-term)Housing repairs assistance (e.g. repair or rebuild of a dwelling)Legal assistance (obtaining services or fees)Mold remediation assistanceShelterTransportation assistance (e.g. local travel, replacement vehicle, moving expenses)Treatment of an illness or physical injury (e.g. replacing prescriptions lost due to the disaster)Utilities assistance (e.g. deposits or monthly expenses for water, electric, gas, heating oil, phone, etc.)Other disaster caused-unmet needs:

Describe your other un-met need(s) not captured above.

RELEASE OF INFORMATION (ROI) AUTHORIZATION

I hereby authorize the State of North Carolina to share my personal and household information with the following agencies, entities, and local partners, as necessary, to support my recovery from Tropical Storm Helene and any other subsequent events that may impact that recovery:

Federal, state, and local government agencies (e.g., FEMA, HUD, NCEM, NCORR, NCDHHS)
Non-profit organizations and long-term recovery groups
Faith-based organizations and community-based groups
Contractors and service providers working on housing repairs, assistance, or temporary shelter
Health and social service agencies

The information shared may include, but is not limited to, the following:

Contact information (e.g., name, phone number, address)
Information about disaster-related damages and needs
Housing status and housing assistance eligibility
Financial assistance applications and awards
Health and social services needs
Any other information necessary for my recovery and to facilitate assistance

Purpose of Information Sharing

The purpose of this authorization is to allow any program working with the State of North Carolina to coordinate with the above-listed entities to provide services and resources that will assist in my recovery, including but not limited to, housing, financial assistance, healthcare, and social services.

Duration of Authorization

This authorization remains in effect for the duration of my recovery unless I revoke it by calling my case manager at (844) 746-2326.

Revocation of Authorization

I understand that I have the right to revoke this authorization at any time verbally, or by submitting a written request to the State of North Carolina. However, I understand that revoking this authorization will not affect any information that has already been shared based on my prior consent.

Confidentiality Assurance I understand the State of North Carolina will only share information necessary to facilitate my recovery and that my information will be kept confidential in accordance with federal, state, and local privacy regulations. By signing below, I acknowledge that I understand the purpose and scope of this release and that I voluntarily authorize the sharing of my information as outlined above.

Signatures

Client Full Legal Name

Date (MM/DD/YYYY)

SAVING AND RESUMING YOUR INFORMATION

Following the guidelines below will aid in timely and accurate processing of your information.
If you are not ready to submit your information, you may use the Save and Resume button at the top of the screen to save your application and resume later.
You will be asked to provide an email address and create a password to resume your saved form later. A confirmation email will be sent to the provided email address with a link to resume the form later. You will need this email address and password to resume your application.
If you do not receive the confirmation email within 15 minutes of saving your information, we recommend that you check your Junk, Bulk-mail, or Spam folder. If you cannot locate the confirmation email, please call (844) 74-NCDCM or (844) 746-2326.

REVIEW, PRINT AND CONFIRM YOUR INFORMATION

Once you hit the "Review, Print, and Confirm" button at the bottom of the page, you will be taken to the final screen to confirm your DCM Intake form.
After reviewing your information on the next page, you MUST click the Confirm button at the bottom of the page to submit your form.
Do not submit more than one form. If you need to make changes to your application, provide additional information or submit supporting documents, call (844) 746-2326 for assistance.

AUTHORIZATION

By submitting this application, I agree that to the best of my knowledge and belief, the facts and statements presented in this application are true and correct. Failure to provide truthful statements may result in the denial of your application.

Client Full Legal Name

Date (MM/DD/YYYY)

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