Client Intake Form

Partner Agency Client Referral Form

Approved partner agency use only (Email info@wewinc.org to get on our partner list).
Welcome!
We're so excited to begin our partnership with you! To ensure we have the information we need to best serve you, please take a few moments to fill out the form below. If you have any questions, please feel free to contact us at info@wewinc.org. Thank you!
Partnering Agency Name *
Agency Name
This form will be maintained; with strict confidentiality and only used by WEW, Inc. Staff to process Career Boutique and furniture requests, make contacts for deliveries and outcome measures, and report demographic/statistical information.
Partnering Agency Contact *

First Name Last Name
EMAIL *
example@example.com
PHONE NUMBER *
Please enter a valid phone number.
REQUEST REGARDING *

Boutique Shopping Hope Project Skill Classes Furniture Request Empowerment Classes Other
If the request is for Boutique shopping. Provide the clothing and shoe size. If the request is for furniture. Please list what is needed. Please note we do not supply any appliances.

What is the primary reason that initiated this request for services? *

Loss of employment/income In retreat/domestic violence Incarceration/re-entry to community Transitional/substance abuse/mental health issue Transitional/homeless (non-specific) Fire/flood/natural disaster Other
Additional Information
File Upload

Cancel of
Please call (214)238-0073 or email info@wewinc.org to confirm receipt of your request.
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Partner Agency Client Referral Form