Application for Assistance
Please complete the form carefully.
Tell us about you
Referred by
Name or Organization
Name
*
First Name
Last Name
Email
*
example@example.com
Birthdate
*
-
Month
-
Day
Year
Date Picker Icon
Phone Number
*
Format: (000) 000-0000.
Is it safe to contact you at this phone number?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ODL/Identification #
*
Emergency Contact Information
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
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
Have you previously applied for assistance from Mercy House?
*
Yes
No
If Yes, when?
Date
Restraining Order
Yes
No
Abuser's Name
First Name
Last Name
Where is the abuser now?
Have you ever lived in a shelter?
Yes
No
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
Please describe children.
Rows
Name
Age
Gender
Child 1
Child 2
Child 3
Child 4
Child 5
Who has legal custody of this child/these children?
First Name
Last Name
The custodian's relationship to the children.
Do you have any children that do not live with you?
Yes
No
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Employment History
Are you employed?
Yes
No
Name of Employer
Income and Resources
What is your current monthly income?
Current Source of income
Income Source Levels - Please enter the amount of support.
Rows
Amount
TANF
Food Stamps
Child Support
SSI/SSD
Cash Assistance
Do you receive WIC?
Yes
No
Amount from WIC
Do you receive Housing Assistance/HUD?
Yes
No
Amount from HUD
Do you use the Oregon Health Plan?
Yes
No
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
Please list all other services you are currently receiving.
Monthly Expenses and Budget
Levels
Rows
Amount
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
Do you have any legal issues pending?
Yes
No
Have you ever had your driver license revoked and/or suspended?
Yes
No
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Additional Information
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 Car 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.
Please enter your name as recognition of authorization.
*
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, including the Department of Human Services, and/or individuals, for the sole purpose of assistance to me from Mercy House in whatever way the Board of Directors decides.
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