DoH Referral and Application for Assistance

Dreams of Hope Foundation Referral and Application
Name of person Completing this form
Name/Relation to applicant
Date of Application

MonthDayYear
Date
Referral Source Name
Referral Source Phone
Format: (000) 000-0000.
Name Applying for Assistance
Last name, First name
Age
Applicant DOB

MonthDayYear
Date
Sex
Marital Status:*

Widow/ WidowerSingleMarriedDivorceSeprated
Is anyone in Household Active duty Military or a Veteran
Social Security Last 4 digits*
Applicant Email
example@example.com
Are you homeless

YesNo
# of Children in house hold.
# of Adults in house hold.
Applicant Race
Senior over age of 55?
Applicant Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Zip Code
Applicant Phone Number 1
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently Employed?

YesNo
Are you on probation?
Do you or anyone in your home have a mental health diagnosis:

NOYES
Is the person with the mental illness currently being treated for their diagnosis?

NOYES
Indicate Diagnosis: Medications: areas could benefit from help
Type of Insurance
Insurance ID Number
Food Pantry

Support GroupFree Mental HealthAnger ManagementCase ManagementTransportationEye Glasses VoucherSubstance AbuseApply for medicaidWednesday Food PantryPrescriptionApply for Food StampsCSFP-monthlyHousingApply for DisabilityResource ConnectOther:
Reason for Referral
Other
Specific Referral
List all People living in the household and sizes.
Applicant's Name
Last name, First name
Applicant's Birthday DOB

MonthDayYear
Date
Person 1 Top Size
Person 1 Bottom Size
Person 1 Shoe Size
Person 2 Name
Person 2 Age
Person 2 Top Size
Person 2 Bottom
Person 2 Shoe Size
Person 3 Top Size
Please check all items in which you would like assistance:

Toilet PaperCoats/JacketRooming houseSoapShirtShampooPantsDeodorantShoesMedication refillsToothpasteSocksMedicationComb/BrushBraLotionUnderwearMedicationConditionerTowelsPads/TamponsWash ClothesMedication PickMedicalCounseling:Can goods BreadSchoolFamily TherapyFood:GroceryIndividual therapyPastaMedicationsGroup therapyVeggies/fruitProbationSubstance Abuse
I understand that items listed are not guaranteed and that assistance is based on the availability.
Initials
Applicant's Signature
Special Notes/ Request
7320 Warwick Boulevard | Newport News, VA 23607 | 757.806.6339 Office|757.277.0911 Fax www.dreamsofhopefoundation.org
Should be Empty: