Assistance Request
(If you would prefer to print this, right-click the page and select 'print')
What is your name/nickname? *
Do you self identify as any of the following? *
What are your pronouns? *
(Please check as many as apply)
Required
Are you over 18? *
Do you have any allergies or dietary restrictions?
What are your favorite hobbies?
What do you like to do in your spare time?
Are you comfortable around animals/children? *
Have you been prescribed any medication? *
What assistance are you currently receiving? *
Please check all that apply (if none, please check 'other' and answer none)
Required
Have you been homeless in the last 12 months? *
(For this question homeless means that you lacked a fixed, regular, and adequate nighttime residence for more than 1 week. Shelters, cars, a friend's couch, abandoned buildings, parks, and other private/public spaces do not qualify as fixed, regular, adequate residence.)
How long were you homeless?
Clear selection
What are your current living arrangements? *
Besides housing, what forms of assistance do you need? *
Required
Do you need to attend any of the following on a regular basis? *
(if none, please check 'other' and answer none)
Required
In what Virginia city / county, do you live or will be relocating? *
Do you own or have regular access to a phone or email address? *
We need a way to contact you. Please select all that apply.
Required
What is your phone number? *
This will be our primary way to contact you.
What is your email address? *
Email will be used to relay important information and all addresses are kept confidential.
Please list your top three emergency contacts (or as many as you can). *
These will remain private and only be used in case of an emergency.
Do you have a regular doctor/hospital in case of emergency? *
Do you have any triggers that your host should be aware of? *
Please list any that you feel comfortable sharing, they will remain private.
If applicable, please list what your host should do to help if you have a panic/anxiety attack or similar issue:
(How can we best help you get through this?)
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