Your Needs

You’re Not Alone

We're here for you

Life can feel heavy sometimes. When you’re facing hard moments — whether it’s putting food on the table, keeping a roof over your head, finding a safe place to stay, or simply needing someone to listen — Harmonie Hearts is here to stand with you.

You don’t have to carry it all by yourself. This is a safe space to share what you’re going through, so we can understand your situation and walk alongside you with care, understanding, and practical help.

This form is for individuals and families in Indiana seeking support from Harmonie Hearts Community Services programs. Submission does not guarantee immediate support. Your information will remain confidential and used only to assess your needs.

Section 1 - Personal Information

MaleFemaleOtherPrefer Not to Say

Address

Section 2 - Household Information

Ages of people in household

Adults (18+)Children (0-17)Elderly (65+)

Household Income

No incomeUnder $1,000 per month$1,000 to $2,000 per month$2,001 to $3,000 per month$3,001 to $4,000 per monthAbove $4,000 per month

Section 3 - Needs Assessment

Food SupportClothingShelter AssistanceEducation SupportSkills Training / EmpowermentOther

Section 4 - Eligibility, Urgency & History

Yes, I reside in the State of IndianaNo, I do not reside in the State of Indiana

Urgency of Help

Emergency (within 24 hours)Urgent (within 7 days)Ongoing need

Section 5 - Contact Preferences

PhoneEmail

Section 6 - Consent

I consent to Harmonie Hearts using this information to assess my needs and to contact me. I understand submission does not guarantee assistance.

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About Us

Harmonie Hearts Community Services fosters hope and opportunities for families in Marion and Hendricks County through food assistance, health programs, and community support.