Name
*
First Name
Last Name
Phone
(###)
###
####
Email
*
How would you like to be contacted?
Email
Text Message
What is the reason you are applying on somebody else’s behalf?
*
Name
*
First Name
Last Name
Email
Phone
(###)
###
####
How would they like to be contacted?
*
Text Message
Email
Please do not contact this person directly
What is their current relationship status?
Single
Separated
Divorced
Married
How many children do they have, and what are their ages?
Are they currently pregnant?
Yes
No
If so, what is their approximate due date?
Are any of their children living with a disability or special needs? (If yes, please provide basic details):
Are there any other dependents in their household? (If so, please provide basic details):
What is their current employment status?
Employed
Unemployed
Part-time
Student
Employer Name and Job Title (if applicable):
Do they receive any government assistance?
What is their current housing situation?
Own
Rent
Living with family/friends
Homeless
Do they have a support network (family, friends, community groups)? (If yes, please describe):
Are they currently involved in any other community programs or receiving support from other organisations? (If yes, please explain):
What are their immediate needs? (e.g., financial assistance, housing, childcare, employment, education, healthcare, etc)
What are you hoping to receive from the Honey and Lemon House on their behalf?
*
Will you or the intended recipient be coming to shop at the Honey and Lemon House?
*
Do you (or they if applicable) have transportation to and from the Honey and Lemon House?
*
Yes
No
Is there anything else you would like us to know about the situation of the intended recipient?
I consent to the use of my personal information by the Honey and Lemon House for the purpose of assessing this application and providing support for the intended recipient.
*
Yes
No
I understand that prior to receiving support from the Honey and Lemon House, I (or the intended recipient) will be required to attend an in person consultation.
*
Yes
No
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
MM
DD
YYYY
How did you hear about the Honey and Lemon House?