PINCH Request Form
PLEASE COMPLETE ONE FORM PER PERSON.  This helps tremendously with processing requests.

This form is for local providers (nonprofits, social service agencies, schools, etc.) to request basic needs items on behalf of their clients who cannot access services themselves.  We can provide 1-2 outfits per request.

If you are an individual who needs assistance, please visit our Clothes Cabin Tues/Weds 9-3pm or Thurs 6-8pm (no appointment needed).

IMPORTANT NOTE:  Providers if you have more than three requests in a week please come in to select items/"shop" for your clients yourself during our regular hours.  We will log assistance under your agency and do not need identifying client information (HIPAA safe).   PINCH orders are emergency assistance and our staff capacity is limited.  We receive a high volume of PINCH orders each week.   
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Email *
Agency Name:    (nonprofit, social service agency, school or other support provider name) *
Your Name: *
Your Email: *
Name of representative picking up the order (if not the same as person completing form):  (please bring agency ID, badge or business card for pick-up) *
Zip code where the CLIENT is living *
Provide as much client detail as appropriate to help us pack this order, it can be helpful to describe the need and the clients preferences.   Example:  6th grade student, loves sports   OR  Example: client is new at our shelter arrived with nothing except clothes on her back, she needs casual wear, does not like dresses!
What is the preferred gender style for clothing/shoe selection
Clear selection
Client approximate age:
Only complete the sections below that are needed for your client.   If an item is not needed leave that section blank.
Clothing Items:  Please list the clothing items that are requested with any style notes, size needed and quantity requested.  Example:  Shirts/casual/large/2, Shorts/elastic waistband/large, Jacket/light/large  
Undergarments: Please list the items requested and the sizes for each.  Example: bra/size 34a, underwear/medium, socks/no show/medium
Shoes:  Please list the type of shoe and size requested.  Example: athletic shoe/size12
Hygiene Goods:
Linens: sometimes in limited supply.
Twin
Queen
King
n/a
Sheets
Blankets
Towels
Baby blankets
School supplies:  We generally have backpacks available year-round and often have school supplies at the start of the school year July-Sept. List what is needed.
Other needs we may be able to help with? (diapers, adult incontinence underwear, adult bladder pads, other)
A copy of your responses will be emailed to the address you provided.
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