Hygiene Assistance Form

Hygiene Assistance Form

For individuals seeking hygiene support services or supplies
Full Name
Date of Birth

MonthDayYear
Date
Phone Number
Email
example@example.com
Current Living Situation (check one):

Unsheltered(street/tent/car)Emergency ShelterTransitionalHousingDoubledUp with Friends/FamilyOther
Requested Hygiene Items (check all that apply)
Toiletries

Toothbrush& ToothpasteSoap/BodyWashDeodorantShampoo/ConditionerLotionFeminine Hygiene ProductsRazors/Shaving CreamComb/BrushNail Clippers
Clothing& Supplies:

SocksUnderwearTowel/WashclothBlanketFace MaskWet Wipes
Additional Needs

Shower AccessLaundry AssistanceMobile Hygiene ServicesOther
Preferred Pick-up or Service Location

Outreach EncounterDrop-in CenterMobile UnitShelterOther
Should be Empty:

Requested Hygiene Items (check all that apply)