Healing Hearts Intake Questionnaire
Mission: The mission of Healing Hearts North Carolina is to help, encourage, advocate, and link individuals and families grappling with hunger and poverty to resources they can access. As part of our efforts to help our clients achieve self-sufficiency and to heal from the traumas caused by poverty, we provide them with food, utility assistance (based upon funding and eligibility), clothing, and behavioral health resources. We strive to encourage our constituents by reflecting God's love, we hope to heal our communities in their effort to fight poverty by providing compassion, encouragement, and attainable tools that will provide relief to individuals and families in the Carolinas. Criteria: -Head of Household on the application must be a US citizen -Must meet income test-Must be able to provide proof of income (SSI/SSD/Paystubs from Employer) -Must have valid ID -Must have SSC at time of application - Must have proof of medical disability or Serious mental Illness -Must be able to provide Proof of Crisis and Utility Bill -Must be located within qualifying counties of services ***Please note, assistance applications for utilities will be evaluated based on current funding for the month. Applicants are encouraged to apply at the beginning of each month and also advised that any payment provided to utility company takes 7-10 business day. Questions: Please send all inquiries to info@healingheartsnc.com and someone with our intake team will reach out within 48 hours. ***
First Name
*
Last Name
*
Email
*
Address: Be sure to include street address, city, state and zip code.
*
Valid Phone number
Date of Birth
Please select what you would like assistance/referral for? Check as many boxes as needed.
Therapy
Utility Assistance
Case management/Support Services (support services includes assistance with mental health, finding affordable housing, food resources, and vocational/employment assistance.)
Food
Clothing
Christmas Giveaway 2025
Turkey Giveaway 2025
Back to School 2026
Outsourced
Please describe why you need assistance from HHNC?
Enter your annual income below:
Are you employed? If so, please provide the name of your employer. If not, please describe your source of income.
Please list all other household members First name, Last Name, and Date of Birth (children, grandchildren,dependents, etc)
Have you received assistance with your local Crisis Agency or Department of Social Service in the last 30 days?
Yes
No
If seeking assistance with utilities, please provide the name of your energy provider? And what is your past due balance as of today's date?
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Please Upload Documents (Such as social security card or license if needed) (Not required for food donations)
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