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

Month Day Year
Date
Referral Source Name
Referral Source Phone
Name Applying for Assistance
Last name, First name
Age
Applicant DOB

Month Day Year
Date
Sex
Marital Status: *

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

Yes No
# of Children in house hold.
# of Adults in house hold.
Applicant Race
Senior over age of 55?
Applicant Address

Address

Street Address Line 2

City State
Zip Code
Applicant Phone Number 1
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Are you currently Employed?

Yes No
Are you on probation?
Do you or anyone in your home have a mental health diagnosis:

NO YES
Is the person with the mental illness currently being treated for their diagnosis?

NO YES
Indicate Diagnosis: Medications: areas could benefit from help
Type of Insurance
Insurance ID Number
Food Pantry

Support Group Free Mental Health Anger Management Case Management Transportation Eye Glasses Voucher Substance Abuse Apply for medicaid Wednesday Food Pantry Prescription Apply for Food Stamps CSFP-monthly Housing Apply for Disability Resource Connect Other:
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

Month Day Year
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 Paper Coats/Jacket Rooming house Soap Shirt Shampoo Pants Deodorant Shoes Medication refills Toothpaste Socks Medication Comb/Brush Bra Lotion Underwear Medication Conditioner Towels Pads/Tampons Wash Clothes Medication Pick Medical Counseling: Can goods Bread School Family Therapy Food: Grocery Individual therapy Pasta Medications Group therapy Veggies/fruit Probation Substance Abuse
I understand that items listed are not guaranteed and that assistance is based on the availability.
Initials
Applicant's Signature

Clear
Special Notes/ Request
7320 Warwick Boulevard | Newport News, VA 23607 | 757.806.6339 Office|757.277.0911 Fax www.dreamsofhopefoundation.org
Should be Empty: