CMCF Good Samaritan Fund Client Outcome Form

Referring Agent Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Name of Referring Agent's Organization(Required)

Please tell us briefly how the support helped your client (choose any that fit):

Helped avoid a crisis (eviction, shutoff, etc.)

Improved financial stability

Addressed an urgent medical or basic need

Reduced stress/improved well-being

Optional: 1–2 sentences about the outcome.(Required)

This information may be shared with donors and potential donors to showcase the impact that the Good Samaritan has on our community.

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