Get Help Form

Assistance Request Application

United Resource Project Assistance Form

Application Form

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.

Full Name:

Phone Number:

APPLICANT's Email Address:

Current Living Situation

Date Of Birth:

Is it safe to call, text or leave a voicemail at this number?

Yes

Preferred Contact Method

Gender:

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

Your role or relationship to the applicant

Case manager

Social Worker

Shelter or housing staff

Healthcare Provider

Mental-health or substance-use provider

Probation or Court Appointed Representative

Family member

Friend or community member

Other

Does the applicant know that you are submitting this request on their behalf?

Yes

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

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

Household Income & Employment Information

Number of adults in household:

Source of Income (Check all that apply):

Employment

SSI / SSDI

Unemployment

TANF/Public Assistance

No income

Other

Are you currently employed?

Yes

Monthly Income:

Are you interested in employment or job readiness resources?

Yes

Are there children currently with you or in your care?

Yes

Number of children in household:

Are you currently receiving any of the following services? Check all that apply

SNAP / Food Stamps

Housing Assistance (Section 8, Rapid Rehousing, etc.)

Medicaid

Medicare

Veteran Services

None

Do you currently have any form of identification? Check all that apply.

Driver’s License / State ID

Social Security Card

Birth Certificate

None

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

Do you have transportation?

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.

Physical Health and Accessibility (Check all that apply)

Mobility limitations

Uses a wheelchair, walker, cane or other mobility device

Difficulty climbing stairs

Hearing impairment

Vision impairment

Communication or language support needed

Seizure disorder

Diabetes

Pregnancy

Current injury, wound or medical concern

Uses oxygen or other medical equipment

Requires help with bathing, dressing, toileting or other personal-care needs

Needs assistance remembering or managing medication

Other physical-health or accessibility need

None

Alcohol and Substance Use

Current Alcohol Use

Current Substance Use

Recent overdose

Possible Withdraw Symptom

May need medical detoxification

Currently receiving substance-use treatment

Currently taking medication for substance-use recovery

Carries or has access to naloxone

Other substance-use concern

None Known

Mental Health and Emotional Support (Check all that apply)

Diagnosed mental-health condition

Recent psychiatric hospitalization

Severe anxiety or panic attacks

Depression

Post-traumatic stress symptoms

Confusion, disorientation or significant memory concerns

Hallucinations or difficulty distinguishing what is real

Difficulty regulating anger

Recent aggressive or threatening behavior

Recent thoughts of self-harm or suicide

Recent thoughts of harming someone else

Sexually inappropriate behavior or comments

Developmental Delays

Compulsive or impulsive behaviors that may affect shared living

Other mental-health or behavioral concern

None known

Can the applicant safely stay in a shared, nonmedical residential environment?

Yes

Does the applicant require medical care, skilled nursing, detoxification or continuous supervision that URP does not provide?

Yes

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

Phone/Mobile

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.

Race/Ethnicity

Have you ever served in the United States Armed Forces?

Yes, Currently Serving

Yes, Previously Served

Prefer not to answer

Do you have a disability or long-term physical, mental, intellectual, developmental, sensory, or medical condition?

Yes

Prefer not to say

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

Acknowledgement

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.

Client Signature:

Date:

Get Help Form

United Resource Project Assistance Form

Application Form

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:

UNITED RESOURCE PROJECT

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