HIH Needs/Resource Checklist

This form helps us understand what you need.
By filling it out, you let us know about your challenges and the kind of help you are looking for.

How to Use This Form

  1. Look at each section.

  2. Select the boxes for every challenge you are facing and every kind of help you need.

  3. If you have questions or need help, just ask a staff member.

First & Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Email *
Zip Code (Where You Stay)
Current Challenges *
Required
Requested Resources *
Required
Support *
Required
Legal *
Required
Financial *
Required
Housing *
Required
Disability *
Required
Clothing *
Required
Education *
Required
Food *
Required
Mental Health *
Required
Physical Wellness *
Required
Employment *
Required
Friends/Family/Faith *
Required
Low-Income Programs *
Required
Transportation *
Required
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