The Honey & Lemon House Application

Thank you for your interest in the Honey and Lemon House!

To apply to shop at our store, please fill in the application below.

Almost all questions are optional to answer, but please note that the more information that you provide, the more likely it is that your application will be accepted.

The purpose of this application is for us to understand your situation and need, enabling us to tailor our support to you individually and effectively. Your information and details will not be shared or sold in any format. We take your privacy seriously.

This form is for those applying for themselves.

If you wish to apply on behalf of somebody else, please use this form instead.

Personal Information

Name

First Name

Last Name

Phone

(###)

###

####

How would you like to be contacted?

Text Message

Family Information

What is your current relationship status?

How many children do you have, and what are their ages?

Are you currently pregnant?

If so, what is your approximate due date?

Are any of your children living with a disability or special needs? (If yes, please provide basic details):

Are there any other dependents in your household? (If so, please provide basic details):

Employment and Financial Information

What is your current employment status?

Employer Name and Job Title (if applicable):

Do you receive any government assistance?

Housing Information

What is your current housing situation?

Support and Community

Do you have a support network (family, friends, community groups)? (If yes, please describe):

Are you currently involved in any community programs or receiving support from other organizations? (If yes, please explain):

Needs Assessment

What are your immediate needs? (e.g., financial assistance, housing, childcare, employment, education, healthcare, etc)

What are you hoping to receive from the Honey and Lemon House?

Do you have transportation to and from the Honey and Lemon House?

Additional Information

Is there anything else you would like us to know about your situation?

Consent and Agreement

I consent to the use of my personal information by the Honey and Lemon House for the purpose of assessing my application and providing support. (Yes/No)

Yes

I understand that prior to receiving support from the Honey and Lemon House, I will be required to attend an in person consultation.

Yes

Liability Disclaimer

By purchasing products or receiving services through the Honey and Lemon House, I acknowledge and agree that neither the Honey and Lemon House, Antioch Australia Ltd, nor any individual involved shall not be held liable for any damages, injuries, or losses incurred as a result of using these products, or receiving any services. All products are sold "as is," without any warranties or guarantees, either express or implied. The Honey and Lemon House does not assume any responsibility for the quality, safety, or effectiveness of the products sold, nor services rendered. It is the buyer's responsibility to use the products as intended and to adhere to any instructions or guidelines provided by the manufacturer. By proceeding with this application, you agree to release Honey and Lemon House from any and all liability related to their services.

I agree

I disagree

Date

YYYY

Optional

How did you hear about our organisation?