Client Inquiry Form

Have you or a household member received services from Matthews HELP Center? --None--Yes No

--Preferred Appt Venue--Phone In-Person at Matthews HELP Center First Available

How many people reside in your household ?

--Gender--Female Male Non-binary Transgender Female Transgender Male Intersex Other Prefer not to say

Date of Birth

Do you wish to receive a text alert regarding your request? Message and data rates may apply. --SMS Opt In--Yes No

--Zip Code--28079 28104 28105 28211 28226 28270

--Primary Need; MHC does not assist with hotel or mortgage payments--Rent Utilities Rent & Utilities Nonfinancial Assistance ONLY Daycare

Do you receive: Medicaid Medicare Both Neither

Date of Eviction/Disconnection:

How much do you need assistance with?

How much can you pay?

Did your financial crisis occur within 6 months of the date you are seeking assistance? --None--Yes No

Briefly describe the situation that has caused you to seek short-term emergency assistance.
What has happened out of the ordinary?

What documentation can you provide as proof of financial crisis? This will be documentation showing the cause of what has happened out of the ordinary, within the last 6 months, to put you in need of assistance. Rental and utility bills/notices cannot be used.

Financial plan moving forward:

I understand that this submission does not guarantee that Matthews HELP Center will be able to assist me with my request: