Client Assistance Request Form - Rapid Re-Housing Program

Safe Harbor has a limited amount of financial assistance for clients who need help with a payment/bill in order to become safe or remain safe after experiencing domestic abuse. Please complete this form with your request. Your Safe Harbor advocate, counselor or housing manager will respond to you within 3 business days with information about whether Safe Harbor can assist with a portion or all of your request. If Safe Harbor is able to assist, we will also share the date when payment can be issued. Payments for bills and rent assistance will be issued directly to your service provider. Safe Harbor will need a copy or photo of your bill before payment can be issued.

Your completion of this request form does not guarantee financial assistance from Safe Harbor. Please check with your advocate, counselor and housing manager on additional community resources where you can also apply for assistance.

First Name is required
Last Name is required
Please enter a 10 digit phone number
Please enter a valid email address
Type of assistance needed
Type of assistance needed is required

Please list your current monthly income:

Please list your current monthly expenses:

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