Application for Assistance
"Remember also those being mistreated, as if you felt their pain in your own bodies" ~Hebrews 13:3
Current Date & Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Referred By
Name or Organization
Full Name
*
First Name
Last Name
Email
*
example@example.com
Date of Birth
*
-
Year
-
Month
Day
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is it safe to contact you on your phone number?
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ODL/Identification #
*
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
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Current Situation
Please explain your current situation---How can we help you today?
Are you currently in any physical danger?
Yes
No
Restraining Order
Yes
No
Abuser's Name
First Name
Last Name
Where is he/she now?
Have you ever lived in a shelter?
Yes
No
If yes, name(s) and location(s)
Assistance History
Have you received assistance from your church?
Yes
No
Have you ever been in any other help programs?
Yes
No
Can your family and friends assist you in any way?
Yes
No
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Family History
Children:
Rows
Name
Age
M/F
Child 1
Male
Female
Child 2
Male
Female
Child 3
Male
Female
Who has legal custody of this child/these children?
Do you have any children that do not live with you?
Yes
No
If yes, please provide their names and who they currently live with:
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Employment History
Are you employed?
Yes
No
If yes, where/how long?
Income and Resources
What is your current monthly income?
Current Source of income
Source Levels
Rows
Level
TANF
Food Stamps
Child Support
SSI/SSD
WIC
Oregon Health Plan
Housing Assistance/HUD
Cash Assistance
Job
DHS Case Worker
First Name
Last Name
DHS Case Worker Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have a child welfare case?
Yes
No
If yes, please explain?
Child Welfare Case Worker
First Name
Last Name
Child Welfare Case Worker Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Please list all other services you are currently receiving:
Monthly Expenses and Budget
Levels
Rows
Amounts
Rent
Utilities
Childcare
Groceries
Auto/Gas
Are you able to make payments on this particular need?
Yes
No
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Criminal History
Have you ever been arrested or charged with a crime?
Yes
No
If yes to any of the above, please explain & provide dates for all arrests and charges, and any programs you were or are currently in:
Do you have any legal issues pending?
Yes
No
If yes, please explain:
Have you ever had your driver license revoked and/or suspended?
Yes
No
If yes, please explain:
Do you have any additional information you would like to provide to help us serve you better?
Valid Picture ID or ODL
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Proof of Care Insurance & Registration (If applicable)
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Authorization
I authorize representatives from Mercy House International, Inc. to speak with other agencies involved in helping me with my current need.
Signature
*
Additional Authorization
By my signature below I authorize representatives of Mercy House International, Inc. to discuss my physical/mental/financial/social situation with other agencies and/or individuals, for the sole purpose of assistance to me from Mercy House in whatever way the Board of Directors decides.
Signature
*
Submit
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