Households Needs Request

The Potter's Hands

Please read the instructions carefully and completely before doing the application.

Note: Only Case Managers or Church Representatives are to submit this application.

REFERRAL:

Each applicant needs to be referred to Potter's Hands by an agency or local church representative. The caseworker/church representative must submit the initial application by email and also accompany the client to the appointment. Please submit the "Household Needs Request" form to send a message before an appointment can be scheduled.

ITEMS NEEDED:

Please include a detailed list of items needed on the form. Caseworker/church leader needs to confirm items requested.

OTHER INFO NEEDED:

Please specify if items can be picked up or need to be delivered. Pick-up within 15 days of appointment is preferred and greatly appreciated. If delivery is needed, please include any special instructions as necessary (floor number, front, side, or rear entrance, etc.).
If a stove is needed, please specify gas or electric.
If beds are needed, please specify quantity and size (queen or twin only). By availability.

FREQUENCY

Clients can only apply to Potter's Hands once every 12 months.

*Although we want to complete every request, we do not have the ability to do so. Given this, The Potter's Hands maintains the right to use discretion regarding priority of requests on a case by case basis.

Request Date

Reason for Need (Please Explain Situation)

Number of Children

Ages

If there are no children, please enter N/A

Organizations Referred By

Name of Case Worker

Phone Number

Email Address

Name of Person Receiving Donation

Address

Floor

City

State

Zip Code

Phone Number

Email Address

Items Requested (be specific)

Religious Affiliation

Prayer Requests

Choose Pickup or Delivery

Delivery

Pickup (must take within 15 days)

The following is to be completed by our office.

Scheduled Delivery Date

Completed by