Pettengill House Request for Services

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.

In the case of a Mental Health Emergency, contact Eliot Community Behavioral Health Centers at 888-769-5201.

Pettengill House serves residents of the following communities: Amesbury, Byfield, Groveland, Merrimac, Newbury, Newburyport, Rowley, Salisbury, and West Newbury.

If you are living out of our service area, please visit our Out of Service Area Resource List.
Name (If you are referring a child, please enter parent/guardian information)

First Name Last Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Primary Phone Number
Alternate Phone Number
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you homeless/without permanent residence?

YesNo
Additional Comments
Have you been economically impacted by COVID-19? (i.e. unemployment, reduced hours, etc.)

YesNo
Additional Comments
Area of assistance needed (please select all that apply)

Advocacy/Case ManagementClothing/Household ItemsFinancial Assistance *(please specify below)Food and/or Personal CareHoliday AssistanceHousingMassHealth Application AssistanceSchool/Education ServicesSchool SuppliesSenior Support (age 60+)SNAP Application AssistanceSubstance/Alcohol Addiction and/or Mental Health Service NavigationSupport for Family/Loved OnesOther
Additional Comments
If you selected financial assistance above, please tell us what area you need assistance with (please select all that apply):

RentMortgageUtilitiesMedical/HealthcareTransportationChildcareChild(ren)'s Education/Remote Learning NeedsClothingOther
Household Information
How many members are in your household (including yourself)?
Please list the other members of your household:
Additional Comments
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)
Referral Info
Referrer's Name

First Name Last Name
Referrer's Agency/Organization
Referrer's Phone Number
Please enter a valid phone number.
Referrer's Email
example@example.com
Does the person you are referring know they are being referred?

YesNo
Reason for Referral (please provide any pertinent information that prompted you to reach out on behalf of this person)
Please verify that you are human*
Should be Empty:

Request for Services Form

Household Information

Referral Info