Client Referral Form

Client Referral Form

Thank you for referring your client. Please complete the form below at least 48-hours in advance of scheduled interview/first day of work. Please email nashville@dressforsuccess.org if you have any questions. Dress for Success is located at 1608 Woodmont Blvd., Nashville, TN, in the YWCA Nashville & Middle TN administrative office building. CLIENTS MUST BE ON TIME TO BE SUITED. REFERRAL AGENCY STAFF OR CASE MANAGERS MAY ACCOMPANY CLIENT, BUT NO CHILDREN OR VISITORS ARE ALLOWED.
Client's Name:

First NameMiddle NameLast Name
What service(s) are you interested in?
PART 1 - REFERRAL INFORMATION
Date of interview/first day of employment? (If not scheduled, please leave blank)

MonthDayYear
Date
Please rate your current level of preparedness for work. (1=Very Unprepared, 2=Unprepared, 3=Somewhat Prepared, 4=Prepared, 5=Very Prepared)

1

2

3

4

5

1 is , 5 is
Type of Appointment:
Referral Agency Name:
Referral Agency Contact Name:
Referral Agency Contact Email
example@example.com
Referral Agency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Check if applicable:
If you checked Self Referral, above, please tell us how you learned about us:
PART 2 - CLIENT INFORMATION
Client DOB:

MonthDayYear
Date
Client Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Client Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Client Email Address:
example@example.com
Public Assistance (e.g. food stamps, public housing)
Highest Level of Education Completed:
Number of Children
Are children currently in client's care?
Client's Marital Status:
Client's Gender:
Client's Race:

Other
Client's Ethnicity:
Client's Preferred Method of Contact:
Please check ALL that apply:
Does client currently have a job?
Job 1 - Employer:
Job 1 - Start Date:

MonthDayYear
Date
Job 1 - Industry:
Job 1 - Please check all that apply:
Job 1 - Compensation:
If paid hourly, how much per hour?
If paid salary, how much per year?
Average number of hours worked per week:
Job 2 - Employer:
Job 2 - Start date:

MonthDayYear
Date
Job 2 - Industry:
Job 2 - Please check all that apply:
Job 2 - Compensation:
If hourly, how much per hour?
If salary, how much per year?
Average number of hours worked per week:
Annual Household Income:
Number of persons in household:
Number of children under 18 in household:
Please check all that apply:
PUBLICITY CONSENT: I give YWCA Nashville & Middle TN permission to use my first name and/or picture on social media platforms, in news articles, magazine stories, videos, or other printed material for educating the public about its programs and services. I understand that compensation will not be provide for use of the material.
Type of clothing needed (i.e. business casual, scrubs, khaki pants, etc.)
Height:
Suit Size:
Top Size:
Pants Size:
Shoe size & preference (i.e. flat, heeled, non-skid soled, etc.)
What else do we need to know?
What is your goal for this program (Check all that apply).

Other
Do you own a computer?
Do you have easy access to a computer?
What type of job are you pursuing? (Select all that apply.)

Other
What challenges do you think you need to overcome to be successfully employed? (Select all that apply)

Other
How much time do you have to work on improving your job readiness skillset? (Select one)
Do you have a resume?
Signature of Client
Should be Empty:

Client Referral Form

PART 1 - REFERRAL INFORMATION

PART 2 - CLIENT INFORMATION