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GO Bag Request
Are you a victim or survivor that has recently left your abuser in the last 6 months? Are you in need of basic toiletries? (Please note "GO BAGS" are available upon request and while supplies last)
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* Indicates required question
Client Name
*
Your answer
Email
*
Your answer
Address where Go Bag will be shipped
*
Your answer
Request date for a Go Bag
*
MM
/
DD
/
YYYY
The best phone number in case we have questions.
*
Your answer
Type of Go Bag needed
Adult
Child
Clear selection
Woman Needs
Women Toiletries
Maxi pads
Tampons
Tooth brush
Tooth paste
Comb
Hair ties
Floss
Hygiene wipes
Deodorant
Other:
Clear selection
Child/ Children Needs
Gender
Boy
Girl
Age of child
Your answer
Child Needs
Tooth brush
Tooth paste
Comb
Granola bars
coloring book
I would like more info on
Resources in my area
DV Advocacy/ Counseling
Trauma Education
Healing art
Support group
How did you hear about Helping Hands Resource Center
FB
IG
Website
Church
Friend
Other:
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