Referral for Assistance
Complete this form for yourself or a client who is in need of assistance. An SHC staff member will then contact the individual seeking services within 2 weeks. If you are requesting assistance in an eviction situation, please call the office or walk in for immediate services. (617)623-6111
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Name *
Phone Number
Email Address
Which way do you prefer to be contacted?
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What is your primary language?
Where are you currently spending the nights? *
In what town/city are you currently staying? *
What agency were you referred by? (if any)
What is your primary need at this moment? *
Required
Please provide a brief explanation of your current situation: *
Submit
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