Request for Services Form
Please provide some info below to help us learn how we may best assist you. All information provided is secure and confidential. Once you have submitted, a Pettengill House staff member will follow up by phone or email within 3-5 business days. Please call (978) 463-8801 with any questions or to schedule an appointment. If you are having a medical emergency, please call 911.
Date of Birth
Primary Phone Number
Alternate Phone Number
Street Address Line 2
State / Province
Postal / Zip Code
Are you homeless/without permanent residence?
Have you been economically impacted by COVID-19? (i.e. unemployment, reduced hours, etc.)
Area of assistance needed (please select all that apply)
Financial Assistance *(please specify below)
Food and/or Personal Care
MassHealth Application Assistance
Mental Health Services
Senior Support (age 60+)
SNAP Application Assistance
Substance/Alcohol Addiction and Mental Health Services
If you selected financial assistance above, please tell us what area you need assistance with (please select all that apply):
Child(ren)'s Education/Remote Learning Needs
How many members are in your household (including yourself)?
Please list the other members of your household:
Are you requesting assistance for yourself or someone else?
Myself (you may skip the next section of the form and click submit)
Someone else (please fill out the referral info below)
Referrer's Phone Number
Please enter a valid phone number.
Does the person you are referring know they are being referred?
Reason for Referral (please provide any pertinent information that prompted you to reach out on behalf of this person)
Should be Empty: