Request for Community Assistance Application Request for Community Assistance Application InstructionsThis form is to be filled out by Behavioral Health providers on behalf of their client known as the "recipient" on this form. Please assist the individual "recipient" or their parent or legal guardian with this form. This community assistance program is dedicated to those active in behavioral health treatment. This program is provided by Still Waters Ministries, Inc.Date of Application MM slash DD slash YYYY Recipient(s) Requesting AssistanceRecipient's Name First Last Parent or Legal Guardian Name First Last This is the family representative and most likely the one requesting assistance.Mobile PhoneHome PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is the recipient currently receiving behavioral health services? Yes No How long has the recipient been in behavioral health services? Former client (not in services) New client - just began services Current client - Less than 6 months Current client - More than 6 months Never been a client 1 year Over 1 year Reasons and Details of Assistance RequestPlease be detailed and specific.What kind of provisions are being requested? Assistance with Water Bill Assistance with Electric Bill Assistance with Gas Bill Assistance with Home Phone Bill Assistance with Mobile Phone Bill Assistance with Rent Assistance with House Payment Assistance with Car Payment Assistance with Vehicle Insurance Assistance with Vehicle Repair Assistance with Vehicle Fuel Assistance with Groceries or Food Assistance with Clothing/Shoes Assistance with Household Supplies Assistance with Medical Bill Assistance with Medical Supplies or Prescriptions Assistance with Toiletries Assistance with Travel Expenses Assistance with Other Please select all that apply.Describe specific need in more detail.Total Amount Needed Utility Company Name / Service Provider Name Account Number Date Due MM slash DD slash YYYY Turn Off Date MM slash DD slash YYYY Phone Number of Utility / ServiceAddressof Utility / Service Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Other Information pertaining to Utility or ServiceSubmitter - Still Waters Staff Members or Associates (Only)Provide contact information of person submitting this form.Name of Person Assisting in Submitting the Form First Last Title or Position Phone of SubmitterEmail of Submitter Behavioral Health Provider Name Still Waters Professional Counseling Services, Inc. Focus on Recovery Heart Mind and Soul Christian Coaching and Counseling Other (please list company name) Other Company Name Submitters' Attestation to Accuracy of Information and Witness to Request I acknowledge all of the information in this application is accurate based on the description given by the potential recipient listed above.Submitters' Attestation to Accuracy of Information and Witness to Request I confirm that the recipient is currently in behavioral health treatment or meets the requirements for eligibility.Submitters' Attestation to the recipient(s) agreement to benefit from this community assistance program. I attest and witness that the potential recipient(s) has/have requested and agreed to receive assistance.Submitter's Signature - Acknowledging Request for Assistance on behalf of the the potential recipient(s). Δ
