Lotus House Financial Assistance Application

Lotus House Financial Assistance Application

Full Name*

What do you like to be called

Phone Number*

Email Address*

example@example.com

Address*

Financial Well-Being Assessment

At Lotus House, we recognize that financial well-being is influenced by systemic factors beyond individual control. This section helps us understand how to best support you.

We approach financial support with the understanding that systemic barriers impact economic stability.

How would you describe your current financial situation? (Select all that apply)*

Financially secureManaging with occasional difficultyExperiencing regular financial strainIn urgent need of assistance

Assistance Request

What type of financial assistance are you requesting? (Check all that apply)*

Funeral or memorial services assistanceCounseling or therapy costsSupport programs (doula, bereavement support, postpartum care, etc.)Other

Please describe how this assistance will support you:*

Supporting Documentation (Optional)

You may provide any documents that help us understand your situation. This is optional and not required to receive support.

Consent & Acknowledgment

I confirm that the information provided is true and complete to the best of my knowledge. I understand that this application is reviewed with care and compassion.

Signature*

Date*

Date