Assistance Application

Request Assistance for Yourself & Your Baby

We are here to support new and expecting mothers by providing resources, baby essentials, and assistance based on available donations. Please complete this confidential form so we can better understand your needs and how we may support you.

Mother Information

Full Name *

Date of Birth

Phone Number *

Email Address *

Address

Preferred Contact Method

Phone Call Email Text Message

I authorize SCMFL to contact me by text message regarding my assistance request.

Employment Status

Race / Ethnicity

Pregnancy Information

Are you currently pregnant?

Yes No

Baby Information

Have you already given birth?

Yes No

Assistance Needed

What items or assistance do you need most?

DiapersBaby WipesFormulaBreastfeeding SuppliesBaby ClothingMaternity ClothingBaby BlanketsCrib/BassinetCar SeatStrollerBaby Hygiene ItemsPostpartum Recovery ItemsHousehold EssentialsFood AssistanceTransportation AssistanceOther

Please describe any additional items or support you need:

Postpartum & Family Support

Do you need postpartum assistance?

Yes No

Do you feel safe in your home environment?

Yes No Prefer not to answer

Do you currently have enough food to eat?

Yes No Sometimes

Are there any urgent needs or challenges you would like us to know about?

Referral Information

How were you referred to SCMFL?

Referral Details

Confidentiality Agreement

SCMFL respects your privacy. All information collected through this assistance request form will remain confidential and will only be used to evaluate your request and provide appropriate support. Your information will not be shared with outside organizations without your permission, except where required by law.

I have read and understand the confidentiality agreement.

Donation Availability Disclaimer

Important Notice: SCMFL provides assistance based on available donations and resources. Submitting this request does not guarantee that all requested items or services will be available. Items provided may include new or gently used donations depending on availability. We appreciate your understanding as we work to support as many mothers and babies as possible.

I understand assistance depends on available donations and resources.

Support Contact

Need help completing this form?

Please contact our support team: donations@scmfl.org

Your request will be sent securely to donations@scmfl.org.