Skip to form
Client Feedback Form
First name:
*
Last name:
*
Email:
*
Help Me Help You Services Provided:
*
Grocery Grab N Go
Long Beach Food Pantry Delivery
CalFresh
Medi-Cal
General Relief
Other
If other, please explain:
Name of Your Advocate:
*
How have Help Me Help You services helped you?
Do you consent to using your quote on our social media platfroms?
*
Yes
No
Do you consent to use your first name and city with your quote on our social media platforms?
*
Yes
No
Upload Photo (only upload your photo if you consent to Help Me Help You using it on our social media platforms).
Upload Photo
Submit