Helping Hands of Barnstead Request of Services Questionnaire

SECTION ONE: CONTACT INFORMATION

Name (Last, First, Middle Initial) ________________________________________________________________
Date of Birth ________________________________________________________________________________
Mailing Address (Street, City, State, Zip) _________________________________________________________
Physical Address (If different) __________________________________________________________________
Home Telephone Number _____________________________________________________________________
Cell Phone Number __________________________________________________________________________
Which is the best number to reach you? _________________________________________________________
Email Address (If applicable) ___________________________________________________________________
Which is the best method to contact you? ________________________________________________________
Current Employer ____________________________________________________________________________
How long have you been working for your current employer? ________________________________________
Spouses Employer (If applicable) _______________________________________________________________
How long has your spouse been working for their current employer? (If applicable) ______________________

SECTION TWO: EARNINGS

TYPE OF INCOME

MONTHLY AVERAGE

EXAMPLE: REGULAR EMPLOYMENT

$1,200

Regular Employment
Unemployment
Workers Compensation
Social Security
Supplemental Security Income
Public Assistance
Veterans Payments
Survivor Benefits

Pension or Retirement Income

Interest
Dividends
Rent
Royalties
Income from Estates
Trusts
Educational Assistance
Alimony
Child Support
Assistance from Outside the Household
Miscellaneous Sources of Income
Income of Additional Household Members (Relatives only)

SECTION THREE: HOUSEHOLD INFORMATION

How many members are in your household? (Relatives only)
What are the ages of each household member?

SECTION FOUR: RECIPIENT INFORMATION

NAME

AGE

GENDER
(M/F)

COAT
SIZE

SHOE
SIZE

PANT
SIZE

SHIRT
SIZE

DRESS OR
SKIRT SIZE

EXAMPLE: JOHN SMITH

28

XXL

12W

40/32

XXL

N/A

1.
2.
3.
4.
5.
6.
7.
8.

SECTION FIVE: ADDITIONAL INFORMATION

In the section below, please notate any additional information that may be helpful in providing you with the
most helpful services. For instance, list if you need any additional baby items such as diapers, school backpacks
for school-aged children, blankets and sizes, space heaters, etc.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

SECTION SIX: POLICIES

I. Helping Hands of Barnstead respects your privacy and will UNDER NO CIRCUMSTANCES distribute any of your
private and personal information to anyone outside of this organization. We are the sole owners of the
information collected on this questionairre and will use it to provide you with the appropriate services you
require. Initial here: ________
II. The individual completing this form understands that the information provided on this document does not
determine whether he or she qualifies for any services provided by Helping Hands of Barnstead. The
information provided on this documentation ensures that you truly need assistance and are not taking
advantage of the generosity of this organization and those who donated items and money to help you. Initial
here: ________
III. By signing below, you agree to re-donate any articles of clothing that are still in fair condition once you or
your household members no longer need them. You understand that Helping Hands of Barnstead is
requesting items to be re-donated so others in need can benefit from them as well. Initial here: ________
IV. By signing below, you certify that the information provided on and in connection with this form is true,
accurate, and complete. You also understand that any false information on this document or any other
document you may file with Helping Hands of Barnstead may be grounds for disqualification from services.
Printed Name ________________________________________________________________________
Signed Name ________________________________________________________________________
Date _______________________________________________________________________________