The Acts 2:45 House Questionnaire

The Acts 2:45 House Questionnaire
We ask that you fill out this questionnaire so we can better support you and your needs. None of this form is required (except those with an asterisk*), but we ask you to fill out as much as you can to help us understand your situation and need for support. Please provide us with either phone number or email, so we may contact you about getting assistance.
Full Name*
Address*
Phone Number
Email Address
example@example.com
Date of Birth*

MonthDayYear
Date
Drivers License Number/Identification
Total number of adults living with you*
Marital Status*
Full Name of Spouse
Children?*
If you have children how many
Employment Status?*
If employed please provide your job and employer
Employer Contact
Monthly household income
What is your current monthly rent/mortgage payment?
Have you recently received or are currently receiving assistance by anyone else?*
Do you or any Household members have dietary restrictions/allergies*
If yes, please specify:
Are there any specific foods or items that you need?
What is your current need for food/clothing assistance?*
How long have you been experiencing a need for assistance
How did you hear about the Acts 2:45 House?*
How long are you anticipating your need of assistance*
How many people in your household require assistance*
Would you be interested in speaking with someone from our church for additional support or counseling?
Please write below a brief explanation of your situation and why you are looking for assistance.*
I certify that this information provided is accurate to the best of my knowledge. I understand that the assistance is provided by the Acts 2:45 house and agree to comply with their guidelines if/when accepted.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

The Acts 2:45 House Questionnaire

I certify that this information provided is accurate to the best of my knowledge. I understand that the assistance is provided by the Acts 2:45 house and agree to comply with their guidelines if/when accepted.