United Way 2-1-1 Disaster Intake Form
Only one disaster intake should be completed per physical address. If you or someone in the household has already completed an intake online or by phone with 2-1-1, please do not complete an additional intake.
Flash Flooding 2022
Date of Disaster/Event:
Street Address and Apt. (if applicable):
St. Louis County, MO
St. Louis City, MO
St. Charles County, MO
St. Clair County, IL
Madison County, IL
Jefferson County, MO
Primary Phone Number:
Alternate Phone Number:
Do you give us permission to share your information with organizations or agencies that may be offering assistance?
Edit section title
Type of Structure:
Single Family Home
Multi Family Structure (apartment, duplex, etc.)
Amount of Water Damage:
Less than 6 inches of water
6 inches to 12 inches of water
1 to 2 feet of water
2 to 3 feet of water
Over 3 feet of water
Location of Water Damage:
Water damage in basement only
Water damage in primary living spaces only
Water damage in BOTH basement and Primary Living Spaces
Trees/Limbs on Home/Structure Only
Trees/Limbs on Property Only
Trees/Limbs on Home/Structure and Property
0-10% of roof is visibly damaged
10-25% of roof is visibly damaged
25-50% of roof is visibly damaged
More than 50% of roof is visibly damaged
Do you need a tarp (s) for the roof?
Is the structural integrity impacted by the wall damage (outer walls and/or load bearing walls damaged)?
Less than two walls are destroyed
Two or more walls are destroyed
Windows and Door Damages:
1-3 Windows or Doors are damaged
4 or more Windows or Doors are damaged
Gutter and Soffit Damages:
0-10% of Gutters or Soffits are damaged
10-25% of Gutters or Soffits are damaged
25-50% of Gutters or Soffits are damaged
More than 50% of Gutters or Soffits are damaged
Mobile Home Damages (only use if structure is a mobile home:
Mobile home has been pushed off foundation only
Mobile home frame has been damaged only
Mobile home has been pushed off foundation AND frame has been damaged
Describe any other structural damage:
Describe damage to personal property:
Are any power lines physically down on the property?
Have you received help from the American Red Cross?
If yes, describe the type of help they provided (financial, food, clothing, vouchers, etc.)
What needs do you still have as a result of the event?
Home Repair - someone to fix damage to my home or funds to help pay for repairs
Temporary Shelter - someplace to stay as my home is uninhabitable due to damages
Tarp to cover roof/someone to tarp my roof
Appliance repair/replacement due to damages
Someone to clean up - not capable of cleaning up the damages
Debris removal - downed limbs/trees
Food - unable to purchase food or store food
Has the property been inspected by the city, county or American Red Cross?
Not yet, but scheduled
Which utilities are not working?:
Has insurance been contacted?
What did insurance say?
Ages of residents
If there are any special needs or considerations in the household, please describe here:
Thank you for completing the United Way 2-1-1 Disaster Intake. Your information will be shared with local Emergency Management Agencies and Community Organizations Active in Disaster (COADs).
**Please note that 2-1-1 will not be able to provide any updates or make changes to your disaster intake form**