Help Request Form

1. Referral Source: *This question is required.

• Self-Referral
• Neighborhood House Employee
• Community Partner

3. How may we contact you? *This question is required.

• Email
• Phone

6. Which of the following benefits are you receiving? Select all that apply. *This question is required.

• EBT/Food Stamps
• TANF
• Medicaid
• Medicare
• None of the above

8. What do you need help with:
  *This question is required.

• Aging and Disability Services
• Applying for employment and training services
• Applying for DSHS cash assistance (TANF)
• Applying for food stamps (SNAP/EBT)
• Applying for health insurance
• Accessing food assistance
• Accessing mental health or substance use treatment
• Currently housed and seeking rental assistance
• Currently homeless (in shelter, car, tent, etc.) and seeking housing services
• Youth afterschool services
• Youth tutoring services
• Citizenship application and classes
• ESL Classes
• Early childhood education and resources (up to 5 years old)

9. Are you a resident of the following housing authorities?  *This question is required.

• King County Housing Authority
• Seattle Housing Authority
• Not Applicable

10. Are you or someone in your household a community college student? *This question is required.

• Yes
• No

10. Are there children under age 18 in the household? *This question is required.

• Yes
• No

11. Are the children in the household students in either the Highline or Tukwila School Districts? *This question is required.

• Yes
• No

11. Are the children in the household students in Seattle Public Schools?

• Yes
• No

11. Are you over age 55? *This question is required.

• Yes
• No

12. Do you have a disability?  *This question is required.

• Yes
• No