Name
*
First Name
Last Name
Email
Phone
(###)
###
####
How would you like to be contacted?
*
Text Message
Email
What is your current relationship status?
Single
Separated
Divorced
Married
How many children do you have, and what are their ages?
Are you currently pregnant?
Yes
No
If so, what is your approximate due date?
Are any of your children living with a disability or special needs? (If yes, please provide basic details):
Are there any other dependents in your household? (If so, please provide basic details):
What is your current employment status?
Employed
Unemployed
Part-time
Student
Employer Name and Job Title (if applicable):
Do you receive any government assistance?
Which option best describes your current financial situation?
*
Please note, many items are free at the Honey and Lemon House with most others priced between $1 and $5
What is your current housing situation?
Own
Rent
Living with family/friends
Homeless
Do you have a support network (family, friends, community groups)? (If yes, please describe):
Are you currently involved in any other community programs or receiving support from other organisations? (If yes, please explain):
What are your immediate needs? (e.g., financial assistance, housing, childcare, employment, education, healthcare, etc)
What are you hoping to receive from the Honey and Lemon House?
*
What packs are you applying for?
*
What items are you in need of?
Do you plan or desire to breastfeed?
*
If you need disposable underwear, what is your size (S, M, L)?
If you need a nursing bra, what is your size?
What is the address for delivery?
*
Any other requests or questions regarding the newborn and postpartum packs?
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.
*
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.
*
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.
*
Date
MM
DD
YYYY
How did you hear about the Honey and Lemon House?
