Urgent Assistance Request Form
Main Information
Full Name:
*
Required
Date
*
Required
Phone
*
Required
Email
*
Required
What WNC County do you currently live in?
*
Buncombe
Haywood
Henderson
Transylvania
McDowell
Burke
Other
1a. What type of bill do you need assistance with?
*
Rent
Utilities (electric, water, gas)
Phone
Transportation (car payment, gas, etc.)
Medical
Other (please specify in question 8 below)
1b. If bill type was not listed, what kind of bill do you need paid?
2. What is the total amount of the bill?
3a. Is this bill currently past due or at risk of disconnection / eviction?
Yes
No
3b. Is yes, please explain urgency:
4. Are you currently in recovery?
Choose one or more options
5a. Do you have a community of support (church, recovery group, family, mentor, etc.)
Yes
No
5b. If yes, please describe:
6a. Are you currently connected to any services or organizations for support?
Yes
No
6b. If yes, which ones?
7. Would you be open to being connected to additional support (peer support, groups, resources)?
Yes
No
8. Briefly describe your current situation and need:
SUBMIT