Mercy Mall Appointment Request
PLEASE READ IN FULL BEFORE FILLING OUT THE REQUEST. THANK YOU.

Mercy Mall provides clothing, household items (not furniture) and baby gear to individuals and families in a CRISIS NEED for those items.

This appointment request form is for individuals and/or families IN CRISIS. Case managers, counselors and/or ministry advocates may fill out this form on behalf of their clients. Please provide updated, correct contact information as our appointment setters will reach out via text. At this time, we are offering drive-thru pick up appointments only.

If your situation is a CRISIS that requires a response within 24 hours, please send a text with your name and description of the crisis to (804) 552-3470 (be sure to give your name when you text).

Bug Infestation Disclosure: Bed Bugs and other bugs are a huge problem in our community! We are here to help in the best way we can. Please know that throwing out beds and furniture does not solve the problem! We ask if you have an active bug situation that you are honest with us. We will still help you, but we need to protect our building and others from an infestation as well.

Mercy Mall offers clothing, household items and baby gear as needed and as available during your drive-thru pick up appointment. We also offer a few food and hygiene items to each family. Once your appointment is booked, you will receive more details about when to arrive, how long the appointment should last and what you need to bring with you.

IMPORTANT: You may receive items that are marked "Good360" during your visit. These items are donated to us through retail partners and CANNOT be sold, traded, or bartered for any goods and services. Thank you for your cooperation in this!

We trust God to provide for you whether it's through Mercy Mall or other sources and we are praying for all of our clients during this very stressful time.
Please read the following and note your agreement/disagreement below.
1. I understand that, at this time, Mercy Mall is only offering drive-thru pick up appointments and that volunteers will pack my items based upon the information provided in this form.
2. I understand that Mercy Mall is a donation based ministry and they may or may not have ALL of the items I request and/or need and that Mercy Mall can make no guarantee that items received operate in their full capacity at the time of receipt or afterwards.
3. I understand that if I provide incomplete information or incorrect details such as sizing, gender, etc. that I may not receive items that fit or meet my needs.
4. I understand that I should only ask for items that I need - ie. I will not ask for a coat if I have a coat, or a set of sheets if I already have sheets on my bed.
5. Clients and/or case managers accept items at their own risk. Mercy Mall is not responsible for any damage to persons or property occurring from the use of any items provided once they leave our boutique.
6. I understand that Mercy Mall staff and volunteers will follow CDC guidelines to provide a clean, healthy and safe environment, to the best of their ability.
Please note your agreement or disagreement regarding the above statement. *
Who should we contact to schedule the appointment? *
First Name of Client *
Last Name of Client *
Mobile Phone Number of Client ~ Please do NOT list case manager phone here, if no phone, write NONE *
Case Manager Name
Case Manager Mobile Number
Describe your crisis situation - do not list your needs here - tell us about the crisis that has caused you to reach out to us for a Crisis Shopping Appointment. If you are NOT in crisis, please seek other resources to meet your clothing, household or baby gear needs. *
Clothing: Name, age, gender and sizes for Person 1 (height/weight, preferences of items needed - ie. work clothes, casual clothes, prefers soft things, bright colors, or no stripes, etc.) Provide sizes for pants (numbered sizes, width/length for men's), shirts, shoes, bra, underwear as needed. *
Clothing: Name, age, sizes and gender of Person 2 (height/weight, preferences of items needed - ie. work clothes, casual clothes, prefers soft things, bright colors, or no stripes, etc.) Provide sizes for pants (numbered sizes, width/length for men's), shirts, shoes, bra, underwear as needed.
Clothing: Name, age, gender and sizes for Person 3 (height/weight, preferences of items needed - ie. work clothes, casual clothes, prefers soft things, bright colors, or no stripes, etc.) Provide sizes for pants (numbered sizes, width/length for men's), shirts, shoes, bra, underwear as needed.
Clothing: Name, age, gender and sizes for Person 4 (height/weight, preferences of items needed - ie. work clothes, casual clothes, prefers soft things, bright colors, or no stripes, etc.) Provide sizes for pants (numbered sizes, width/length for men's), shirts, shoes, bra, underwear as needed.
Clothing: Name, age, gender and sizes for Persons 5+ (height/weight, preferences of items needed - ie. work clothes, casual clothes, prefers soft things, bright colors, or no stripes, etc.) For sizes give pants (numbered sizes, width/length for men's), shirts, shoes, bra, underwear. If you have more than 5 people in your home that need clothing, you can list the rest here.
Housing Situation *
If new housing, what is/was your move in date?
Address of Client (if Homeless, write Homeless) *
Total number of people in the home *
Household Items
Mercy Mall provides small household items (as needed and when available). We ask that you DO NOT ask for items you already have - we ONLY provide items when you have NONE of the item - we are a Crisis Focused Ministry. For example, if you have sheets on your bed, please DO NOT ask for another set of sheets but you have NO towels and need one for each person in your home, DO ask for towels. If you are starting over from scratch with NOTHING, please tell us that in the spaces below! Mercy Mall does NOT provide furniture. Please also note that Mercy Mall is a donation based ministry - we do not guarantee to provide ALL items requested and we cannot guarantee the effectiveness of those items.
Please note your agreement and understanding of the above information and check the statement below that applies to your immediate situation. *
If you have bed bugs or recently dealt with bed bugs, please fill out this survey and then text 804-552-3470 that it's been completed. https://goo.gl/forms/BgJFptKitEdOKQoG2 *
Household items: Kitchen ~ tell us what specific items you need for your kitchen (ex. pot/pan, cookware, utensils, coffee pot, toaster, other counter top appliances etc). If you need a coffee pot, please specify Keurig style or Drip Style. If none are needed, please write NONE
Household items: Bedroom ~ tell us what specific items you need for your bedroom. Be sure to include bed sizes and how many beds for sheets (ex. 1 Q sheet/comforter or 2 T sheets if you have 2 twin beds and NO sheets on them). If none are needed, please write NONE. Mercy Mall does NOT provide furniture. If you do NOT have beds - please mention that here, we can provide you with a list of furniture resources.
Bathroom Items - tell us what items you need for your bathroom and how many bathrooms are in your home (ex 1 full, or 1 full and 1 half, etc.). Examples of Bathroom items: shower curtain, towels, wash cloths, bath mat, etc. If none are needed, please write NONE.
Household items: Living Room/Other ~ tell us what items you need for your living room or other areas of your home. If you need curtains, please tell us how many windows. (Examples of Other items: table lamp, floor lamp, vacuum). If none are needed, please write NONE. Mercy Mall does NOT provide furniture.
Baby Gear
Mercy Mall provides (as needed and when available) baby clothes, a few diapers/wipes and larger baby gear for moms-to-be, within 30 days of their baby's due date as well as after baby is born up to age 24 mos. We are a CRISIS Focused ministry and encourage you to seek other resources for those needs if you have time before baby is due or before the item is needed. Please consider your current housing situation and space when asking for larger items. Mercy Mall DOES NOT provide cribs - we may offer a pack n play, bassinet, or other sleep space for infants, when available. Reminder, Mercy Mall is a donation based ministry and makes no guarantee to provide all of the items you request.
Please note your agreement/disagreement with the above statement. *
If you are currently pregnant, what is your due date?
Baby Gear (not clothes but gear for babies age 0 - 24 mos). Please list the name, age and gender of baby/babies in your household. Please request items you need most - such as a pack n play because baby has nowhere else to sleep, car seat if you do NOT have one, bottles, diapers (size), wipes, etc.
Food: We offer a few non-perishable food items to each client, as needed and when available. Let us know your food preference by picking the best option for your immediate situation. *
Mercy Mall may provide you with hygiene items or toiletries, if available (shampoo, soap, laundry detergent, etc). Please list 5 items that you would like to receive, if we have them. Please write NONE if you do not need hygiene/toiletry items at this time. *
If you are a Crisis Case Manager, what date will services end for this client? (If less than 7 days, Mercy Mall cannot guarantee an appointment before services run out) We will do our best to serve your client within the time frame provided.
Case Manager E-mail address (We would like to add you to our Case Manager's Corner email - helpful tips and information about Mercy Mall - you can unsubscribe anytime you wish).
E-mail of Client - PLEASE DO NOT USE CASE MANAGER E-MAIL HERE! If client has no email, please write NONE.
Prayer Request: Please use this space to tell us your prayer needs. We consider it a privilege and honor to lift up your needs before God! He loves you and cares about you and so do we.
At this time we are offering No-Contact Drive-thru pick up appointments to all clients in crisis. *
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