The Honey & Lemon House Application

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

To apply on behalf of somebody else 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 each individual situation and need, enabling us to tailor our support individually and effectively. All information provided will not be shared or sold in any format. We take your privacy seriously.

This form is for those applying on behalf of somebody else. If you wish to apply for yourself, please use this form instead.

Your Information (applicant)

Name

First Name

Last Name

Phone

(###)

###

####

How would you like to be contacted?

Text Message

What is the reason you are applying on somebody else’s behalf?

Their Information (intended recipient of services)

Name

First Name

Last Name

Phone

(###)

###

####

How would they like to be contacted?

Family Information of intended recipient

What is their current relationship status?

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

Are they currently pregnant?

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):

Employment and Financial Information of intended recipient

What is their current employment status?

Employer Name and Job Title (if applicable):

Do they receive any government assistance?

Housing Information

What is their current housing situation?

Support and Community

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):

Needs Assessment

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?

Additional Information

Is there anything else you would like us to know about the situation of the intended recipient?

Consent and Agreement

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

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

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 the Honey and Lemon House?