Assistance Request Application - United Resource Project INC

Applicant's Information

Use this section to share the person in need of help's information. If you are a referring partner who would also like to be CC'd please include your contact info as well.

Are you completing this form for yourself or for someone else?

I am completing this form for myself

I am completing this form for someone else

Referring Person or Agency Information

First Name

Last Name

Phone/Mobile

Who should URP contact first regarding this request?

Contact the applicant first

Contact me first

Either person may be contacted

Request Assistance

What type of assistance are you requesting?

Please note: URP does not offer rental, utility, or gas assistance at this time.

Check all that apply.

Emergency Housing ( A bed in our transitional house. ADULTS ONLY)

Food Assistance

Hygiene Supplies

Clothing Assistance (From our clothing closet. We do not purchase new clothing)

Mental Health Resources

Substance Use Resources

Job/Employment Resources

Financial Literacy Assistance

Other

Are you requesting a temporary bed in URP’s transitional home?

Yes

If you do not need a bed- briefly explain what you are requesting assistance with. URP DOES NOT PROVIDE ASSISTANCE WITH RENTAL, UTILITY OR GAS CARDS

Household Income & Employment Information

Do you have transportation?

Yes

Temporary Bed Request

What date are you requesting a bed for?

Have you stayed at URP before?

Yes

Are you 18 years of age or older?

Yes

If offered a bed, can you arrive between 3:30 PM and 6:30 PM?

Yes

Health, Safety and Support Information

To help URP prepare for a safe and supportive stay, please check every item that currently applies to the applicant. Selecting an item does not automatically disqualify someone from receiving assistance. URP may contact the applicant or referring professional for additional information.

Please explain any items selected above.

Are you currently receiving services or support from a healthcare provider, mental health professional, case manager, counselor, treatment program or community agency?

Yes

Please provide the name of the provider, professional or agency, their role, and contact information.

Does the applicant have any history of sexual or physical violence?

Yes

If yes- please provide more details

Is there anything else we should know about this applicant?

Emergency Contact Information

First Name

Last Name

You must check ALL boxes

I understand that emergency beds are limited and may not be available at the time of my request.

I understand that if I am offered an emergency bed, I must report for check-in between 3:30 PM and 6:30 PM.

I understand that emergency bed placement is for THREE nights only, and checkout is at 12:00 PM on checkout day.

I understand that beds are available on a first-come, first-served basis and that if I do not arrive within 30 minutes of my assigned check-in time, I may lose my bed.

I understand that I may not bring more than 2 bags.

I understand that URP’s transitional home is for adults only and children are not allowed on site.

Optional Demographic Information

URP collects demographic information to understand the populations we serve, improve services, and complete grant and community-impact reporting. Your responses will not affect your eligibility for assistance or bed placement.

Is there anyone else you would like URP to copy (CC) on email communication regarding this request?

Yes

Additional Contact

URP will only share information neccessary to respond to this request. Please do not list anyone who does not have the applicant's permission to receive updates.

First Name

Last Name

Phone/Mobile

Relationship to the applicant or role

Does the applicant give permission for URP to share updates about this request with this person?

Yes

Unsure

You must check ALL boxes

I understand that submitting this form does not guarantee assistance, services, or bed placement.

I understand that I must monitor my phone for a call, text, or email to discuss my request.

Consent & Privacy Agreement:

By signing below, I agree that the information provided is accurate. I understand that my personal information will be kept confidential and used
only for service coordination.

United Resource Project Assistance Form

Applicant's Information

Referring Person or Agency Information

Request Assistance

Household Income & Employment Information

Temporary Bed Request

Health, Safety and Support Information

Emergency Contact Information

Optional Demographic Information

Additional Contact

Acknowledgement

Consent & Privacy Agreement: