Client Inquiry Form

Date of Birth:

--Zip Code--28079 28104 28105 28226 28270 Not within MHC Service Area

--How did you learn about MHC?--Faith Community MHC Board/Staff Member Non-Profit Partner, Crisis Assistance Ministries Non-Profit Partner, DSS Non-Profit Partner, Family Services Network Non-Profit Partner, Other Non-Profit Partner, Servant's Heart Other Social Media/Website Word of Mouth, Friend/Family Word of Mouth, Landlord Word of Mouth, Service Provider

What do you need assistance with? (select all that apply):
Rent/Mortgage Utilities Bus Passes/Gasoline Food Clothing

Date of Eviction/Disconnection:

Have you or a household member received services from Matthews HELP Center? --Please Select--Yes No

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