Please fill out the form below and press the “Submit Application” button when completed.
1. What type of help are you requesting?
2. Describe how this item or service helps your client. (Within the rules of confidentiality, please be as specific a possible while describing the issues facing your client.)
3. Please describe what other attempts have been made to secure this item or service.
4. The following information is required before we can facilitate your request: (All details regarding the specific item or service must be provided because we are unable to find items or services for your client. We just try to help pay for them.)
5. Include all additional information that might expedite your request:
6. So that we may contact you promptly, please provide the following.
7. By submitting this form, I acknowledge that I will be expected to help arrange the item / service for my client since I understand that no money will be given to clients directly. (check box)
8. I also agree that if this request is approved, I will be willing to discuss what impact (if any) this service had for my client, at a future date, with a 'One Can Help' staff member. (check box)
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