News
Resources
508.430.8111
info@wecancenter.org
783 Route 28
Harwich Port, MA 02646
Donate Now
Home
About Us
About Us
History
How WE CAN Helps
Business & Community Partners
Staff
Board of Directors
WE CAN Newsletters
WE CAN Stories
Videos
Services
Latest E-News and Programs
Services
Information & Referral
Business Support
Career Support
Financial Empowerment
Legal Services
Calendar
Printable Program List
February 26 – Family Law Overview
March 10 – Optimize Your LinkedIn Profile
April 23 – Family Law Overview
Volunteer
Volunteer
Volunteer Form
WE CAN Events
Event List
20th Anniversary
W3: A Day of Words, Wit & Wisdom 2021
Events: WE CAN 2020 Virtual Community Breakfast
The Gasp 2020
Host an Event
News
Resources
Why I Give
Donate
Donate
Annual Fund
Champions
Community Builders
Endowment
Planned Giving
Other Ways to Give
Contact
WE CAN Intake Form
Name
*
First
Middle
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ã…land Islands
Country
Best Phone
*
Type of phone
*
Cell
Home
Buisiness
OK to leave messages?
Yes
No
OK to text?
Yes
No
Not a cell phone
Alternate Phone
Type of phone
Cell
Home
Buisiness
OK to leave messages?
Yes
No
OK to text?
Yes
No
Not a cell phone
Email
OK to email?
Yes
No
Check here if you do NOT want to receive our E-Newsletter
How did you hear about us?
Counselor
Co-Worker/Employer
Driving By
Friend/Family
Internet/Website
Newspaper
Radio
Local TV
WE CAN Brochure
Other Professional
Other Organization
Have you ever received WE CAN services before today?
Yes
No
If so, do you remember when and how we helped?
Why did you contact us? How can we help you?
Divorce
Mentoring
Financial Related
Legal Matter
Work Support
Other
If other, explain:
CONFIDENTIAL
This information is helpful for our anonymous reporting to our funding sources and securing grant monies.
Date of Birth
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Marital Status:
Single
Married
Domestic Partner
Divorced
Separated
Widowed
Gender:
Last year of school completed
Less than 12
High School
GED
12+
Associate Degree
Bachelor's Degree
Master's Degree
Advanced Degree
Other
Are you in need of permanent housing?
Yes
No
Are you homeless?
Yes
No
What best describes your living situation?
Own
Rent
Live with Friends/Family
Employment Status
Employed
Self-Employed
UNDER-Employed
Retired
Unemployed
We want to know how many people are impacted by our help, so we want to know how many people TOTAL are in your household?
Single Parent Household?
Number of Adults
Number of Children
Household Income
Under 10,000
10,001 - 15,000
15,001 - 20,000
20,001 - 25,000
25,001 - 30,000
30,001 - 35,000
35,001 - 40,000
40,001 - 45,000
45,001 - 50,000
50,001 - 55,000
55,001 - 60,000
60,001 - 65,000
65,001 - 70,000
70,001 - 75,000
75,001 - 80,000
80,001 - 85,000
85,001+
Primary Language:
Race Self-Identification: (Check all that apply):
African American/Black
Asian
Caucasian
Multi Racial
Native American/Alaskan/Inuit
Pacific Islander
Ethnicity Self-Identification: (Check all that apply):
Azores
Brazilian
Cape Verdean
Ecuadorian
European American
Haitian
Hispanic/Latino
Indian Sub-Continent
Mexican
Middle Eastern
Multi-Ethnic
Portuguese
Salvadorian
Other
If other:
Do you or anyone in your family receive?
Mass Health
Disability Income
SSI/SSDI
WIC
VA Benefits
Food Stamps
Worker’s Comp
Transitional Aid to Needy Families (TANF)
Unemployment
Social Security
Reduced Lunch
Other
If other:
Do you or anyone in your family receive subsidized:
Health Care
Housing
Child Care
Confidentiality Policy
WE CAN is committed to making this a safe space for all of us.
Our policy on confidentiality states that everything participants share with staff and volunteers is confidential unless a participant shares they are going to hurt themselves or someone else, or if a child, elder or disabled person is being abused or neglected.
Within our groups and workshops, participants will keep confidential all that is shared in the meetings. WE CAN staff reserves the right to ask a participant to leave our programming if we have reason to believe that the confidentiality of the group is violated.
Confidentiality Policy Agreement
*
I have read and agree to the confidentiality policy.
Substance Use Policy
WE CAN requires that a participant be sober and not use alcohol or drugs on the day of a walk in, appointment, workshop or group. This is necessary for WE CAN to provide a safe space for our programming and events and to support women in recovery as well as women who have been impacted by loved ones who have or had a substance use disorder.
If a participant appears intoxicated or under the influence of drugs, WE CAN will ask the participant to leave the group, workshop, appointment etc and arrange a sober ride home (friend, family, taxi) with assistance from WE CAN. If a participant leaves the premises while driving a vehicle and appearing intoxicated/under the influence of drugs, the WE CAN staff/intern/volunteer must call the police to notify them with the participant’s name and a description of the vehicle.
WE CAN staff and volunteers reserve the right to call local Rescue at 911 if we have serious concerns about a participant’s health (including intoxication/under the influence of drugs) to ask Rescue to make an assessment.
Substance Policy Agreement
*
I have read and agree to the substance policy policy.
CAPTCHA
Signature
Menu
Translate »