Client Referral Request
**This form can only be completed by a verified Social Worker and a qualified referring Agency.
Please Read:
**At this time we are only able to deliver to addresses that are within a 20 mile radius of the warehouse, which is located at 400 Roberts Road, Oldsmar, FL 34677. **We are only able to help a select number of families per month, based on available donations and resources. Priorities are given to families who have nothing and families who are sleeping on the floor or caring for foster children. Please provide as much information as possible about your client and their situation.
Notice:
Please do not complete an application if the client is not currently living in their home, or their move-in date is more than two weeks in the future. Part of our screening process requires the client to send pictures of their living space so we can properly assess their needs. If they aren't in the home yet we can't complete our screening process.
Social Worker Information
Name of Referring Agency
*
Please Select
ACTS
Camelot Community Care
Catholic Charities
Children's Board
Children's Home Network/SEEDS
Church World Service
Coptic Orthodox Charities
Created Women
Dawning Family Services
DCF/Hope Florida
Endeavors
Feeding Tampa Bay
Florida Guardian ad Litem
Foster Closet
Grace Family Church
Gulf Coast JFCS
Health Connect America
Hillsborough County Schools
Hillsborough House of Hope
Idlewild Baptist Church
Just Initiative
Love, Inc.
Lutheran Services Florida
Mattie Williams Neighborhood Family Center
Metropolitan Ministries
New Life Village
Pasco County Schools
Pinellas County Job Corps
Positive Spin
Redeeming Love Foster Closet
Salvation Army
St. Timothy Care Portal
St. Vincent de Paul
Survivor Ventures
Tampa Family Health Center
Tampa Housing Authority
The Spring
Ukrainian Sponsor
United Way
Veterans Affairs (HUD VASH)
Volunteers of America, Florida
**This form can only be completed by an actual Social Worker and a qualified referring agency. Referrals will be verified. If your agency is not listed please refer your family/individual to one of the qualified agencies listed.
Social Worker Full Name
*
First Name
Last Name
Social Worker E-mail
*
example@example.com
Social Worker Phone Number
*
Please enter a valid phone number.
Full name of Social Worker's Supervisor
*
First Name
Last Name
Supervisor's Email
*
example@example.com
Supervisor's Phone Number
*
Please enter a valid phone number.
Client Information
Client Full Name
*
First Name
Last Name
Client Email
*
example@example.com
Client Phone Number
*
Please enter a valid phone number.
Alternate Phone Number (see notes below)
This should be a phone number that allows us to reach the client in the event that they don't have a phone. It should not be a social worker number. If we can't call the client directly it could be the number of a friend or family member. This is NOT a required field.
Client Address (must be within 20 miles of warehouse in Oldsmar)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the client a veteran?
*
Please Select
Yes
No
In which branch of the military did they serve?
Please Select
Air Force
Army
Coast Guard
Marine Corps
Navy
Space Force
How old is the client?
*
What is the client's gender?
*
Please Select
Female
Male
What is the client's race?
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Unknown/Other
How long have you known the client?
*
Have you met the client in person?
*
Please Select
Yes
No
Have you visited the client's home?
*
Please Select
Yes
No
Situation that is causing your client to need assistance from New Life Warehouse:
Was your client homeless within the last two months?
*
Yes
No
Choose the most recent event that contributed to their need for furniture and household supplies:
*
Recent Domestic Violence situation
Recent Human Trafficking situation
Recent Tragedy (hurricane/mold/water damage/vermin/insects/fire/death of breadwinner/hurricane, etc.)
Recently Aged Out of Foster Care System
Recent rehoming of a Veteran
Recently Homed Refugee or Migrant
Now meeting Reunification requirements
Disability
New Foster Care/Kinship situation
Job Loss
Living in poverty without basic necessary furniture (like beds or tables)
Which current situation best describes what has caused your client to need furniture and household goods:
*
Taking in foster children or kinship (relatives)
Damaged furniture due to infestation, water, fire or mold (or other tragedy)
Living in poverty without basic necessary furniture (like beds or tables)
Just Aged Out of Foster Care System and can't afford furniture
Disability and can't afford furniture
Recent Domestic Violence incident and can't afford furniture
Recent Human Trafficking and can't afford furniture
Reunification and can't afford furniture
Resettled Refugee and can't afford furniture
Which situation best describes what has caused your client to need furniture?
Aged Out - Homeless
Aged Out - Poverty
Disability / Homeless
Disability / Poverty
Domestic Violence - Homeless
Domestic Violence - Poverty
Foster Care/Kinship - Homeless
Foster Care/Kinship - Poverty
Homeless
Poverty
Refugee/Migrant - Homeless
Refugee/Migrant - Poverty
Reunification - Homeless
Reunification - Poverty
Trafficking - Homeless
Trafficking - Poverty
Tragedy - Homeless
Tragedy - Poverty
Other
Choose Tragedy Type
*
Please Select
Hurricane
Fire
Death of Breadwinner
Mold/Water Damage
Vermin/Insects
Other
Please provide specific details about the Tragedy.
*
Include name of Hurricane, if applicable.
Please provide more details about the Tragedy:
*
Please Select
Hurricane
Fire
Death of Breadwinner
Mold/water damage
Vermin/insects
Other
**If providing details about a Hurricane, please list the name of the storm.
What services has your agency provided the client?
*
Has the family been referred to or served by New Life Warehouse before?
*
Please Select
Yes
No
Not Sure
Have you referred the client to any other organizations for furniture or household goods? (Please list the organizations.)
*
Back
Next
What language does the client speak?
*
English
Spanish
Russian
Ukrainian
Other
If family speaks a language other than English, please share their Country of Origin.
Are there children living in the home?
*
Yes
No
How many children are living in the home?
*
Please Select
1
2
3
4
5
6
7
8
Name of Child #1
*
First Name
Last Name
Gender of Child #1
*
Please Select
Male
Female
Age of Child #1
*
Please Select
infant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Race of Child #1
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Name of Child #2
*
First Name
Last Name
Gender of Child #2
*
Please Select
Male
Female
Age of Child #2
*
Please Select
infant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Race of Child #2
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Name of Child #3
*
First Name
Last Name
Gender of Child #3
*
Please Select
Male
Female
Age of Child #3
*
Please Select
infant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Race of Child #3
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Name of Child #4
*
First Name
Last Name
Gender of Child #4
*
Please Select
Male
Female
Age of Child #4
*
Please Select
infant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Race of Child #4
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Name of Child #5
*
First Name
Last Name
Gender of Child #5
*
Please Select
Male
Female
Age of Child #5
*
Please Select
infant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Race of Child #5
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Name of Child #6
*
First Name
Last Name
Gender of Child #6
*
Please Select
Male
Female
Age of Child #6
*
Please Select
infant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Race of Child #6
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Name of Child #7
*
First Name
Last Name
Gender of Child #7
*
Please Select
Male
Female
Age of Child #7
*
Please Select
infant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Race of Child #7
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Name of Child #8
*
First Name
Last Name
Gender of Child #8
*
Please Select
Male
Female
Age of Child #8
*
Please Select
infant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Race of Child #8
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Please complete for each child in the home.
*
Rows
Child First Name
Child Last Name
Child Gender
Child Age
Child #1
Male
Female
Child #2
Male
Female
Child #3
Male
Female
Child #4
Male
Female
Child #5
Male
Female
Child #6
Male
Female
Number of children.
*
Number of adults in the home.
*
Are there other adults living in the home?
*
Yes
No
How many other adults are living in the home?
*
Please Select
1
2
3
4
5
6
Name of Adult #1
*
First Name
Last Name
Age of Adult #1
*
Gender of Adult #1
*
Please Select
male
female
Race of Adult #1
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Relationship of Adult #1 (son, daughter, spouse, mother, cousin, friend, etc.)
*
Name of Adult #2
*
First Name
Last Name
Age of Adult #2
*
Gender of Adult #2
*
Please Select
male
female
Race of Adult #2
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Relationship of Adult #2 (son, daughter, spouse, mother, cousin, friend, etc.)
*
Name of Adult #3
*
First Name
Last Name
Age of Adult #3
*
Gender of Adult #3
*
Please Select
male
female
Race of Adult #3
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Relationship of Adult #3 (son, daughter, spouse, mother, cousin, friend, etc.)
*
Name of Adult #4
*
First Name
Last Name
Age of Adult #4
*
Gender of Adult #4
*
Please Select
male
female
Race of Adult #4
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Relationship of Adult #4 (son, daughter, spouse, mother, cousin, friend, etc.)
*
Name of Adult #5
*
First Name
Last Name
Age of Adult #5
*
Gender of Adult #5
*
Please Select
male
female
Race of Adult #5
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Relationship of Adult #5 (son, daughter, spouse, mother, cousin, friend, etc.)
*
Name of Adult #6
*
First Name
Last Name
Age of Adult #6
*
Gender of Adult #6
*
Please Select
male
female
Race of Adult #6
*
Please Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Relationship of Adult #6 (son, daughter, spouse, mother, cousin, friend, etc.)
*
Please complete for each adult living in the home.
*
Rows
First Name
Last Name
Age
Gender
Relationship
Adult #1
Male
Female
Adult #2
Male
Female
Adult #3
Male
Female
Adult #4
Male
Female
Adult #5
Male
Female
Adult #6
Male
Female
Please provide full names for all adults living in the home.
*
Does anyone in the family have a disability?
*
Please Select
Yes
No
Please list the family members with disabilities, and provide details about the disability.
*
Is there anyone in the home who is 65 years or older?
*
Please Select
Yes
No
Age and gender of each person in the family. (Please include ages of adults).
*
Briefly describe the client's situation. What caused them to need furniture?
*
Which option best describes your client's furniture situation?
*
Client is in empty home and has no furniture at all.
Client has most essential furniture but is in need of just a few items.
Client has furniture but it is old and/or broken.
Client is in need of beds only.
What specific pieces of furniture does the client need? (Please list room by room.)
*
Please describe the specific help you are requesting from New Life Warehouse for your client.
*
Does the family currently live in the house or apartment?
*
Yes
No
How long has the family resided at the current address?
*
Move-in Date or expected move-in date for new residence.
*
-
Month
-
Day
Year
Date
How is the family paying for their rent?
*
Client is employed
Rent is being paid by an agency
Section 8 Housing
Other
New Life Warehouse will only serve a family one time. We don't want to deliver furniture to a family who will be unable to stay in their current residence. Knowing that, is this the proper time for them to receive furniture?
*
Yes
No
Other
On a scale of 1 to 10, how stable do you think the family is? (1 = very unstable, 10 = very stable.)
*
Please Select
1
2
3
4
5
6
7
8
9
10
Why did you rate the family as 5 or less for stability?
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Next
Final Internal Process Details - Please read through the following statements and confirm that you understand what happens once your referral is submitted.
I understand that New Life Warehouse will review the referral I've submitted for my client and make a determination on whether the referral can be advanced or denied.
*
Please Select
Yes
No
I understand that if my referral meets the initial criteria, the client must fill out a SEPARATE APPLICATION. It is called NLW Application for Assistance and it is MANDATORY.
*
Please Select
Yes
No
I understand that I as the Social Worker am responsible for sending that application to the client. I MUST TEXT or EMAIL the application link to the client. (The link will be provided to you by email if your application is being advanced.)
*
Please Select
Yes
No
We suggest texting the link to the clients as not everyone checks their email.
I understand that the Client MUST COMPLETE AND SUBMIT the NLW Application for Assistance within 5 days or their request will be declined.
Please Select
Yes
No
Do you believe your client is capable of completing the NLW Application for Assistance?
*
Please Select
Yes
No
Why is the client not capable of completing the application?
*
Client doesn't read English
Client doesn't have phone or email
Client isn't technically savvy enough to complete the form
Other
How did you hear about us?
*
Submit
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