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 Name
Middle Name
Last Name
What service(s) are you interested in?
*
Dress for Success (please complete parts 1,2,3)
Career Services / EmpowerHER (please complete parts 1,2,4)
Both (please complete parts 1,2,3,4)
PART 1 - REFERRAL INFORMATION
Date of interview/first day of employment? (If not scheduled, please leave blank)
-
Month
-
Day
Year
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:
*
Interview Suiting
Employment Suiting
Training Suiting
Career Services
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.
Check if applicable:
Self Referral
If you checked Self Referral, above, please tell us how you learned about us:
Website
Community Fair or Informational Event
Brochure
Friend or relative
Employer
Other
PART 2 - CLIENT INFORMATION
Client DOB:
*
-
Month
-
Day
Year
Date
Client Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Home Phone:
Please enter a valid phone number.
Client Cell Phone:
*
Please enter a valid phone number.
Client Email Address:
example@example.com
Public Assistance (e.g. food stamps, public housing)
*
Yes
No
Highest Level of Education Completed:
*
8th grade
9th grade
10th grade
11th grade
12th grade
GED / HiSET
Some College
2yr Degree
4yr Degree
Grad School
Number of Children
*
None
1
2
3
4
5+
Are children currently in client's care?
*
Yes
No
Some
Client's Marital Status:
*
Single
Married
Divorced
Separated
Widowed
Client's Gender:
*
Male
Female
Transgender Male
Transgender Female
Gender Non-Conforming
Other
Client refused to provide.
Client's Race:
*
Native American / Alaskan Native
Asian
Australian Aboriginal
Black or African American
Hispanic / Latina
Maori
Multiple/Mixed
Native Hawaiian / Pacific Islander
White Non-Latino/Caucasian
Unknown
Other
Client's Ethnicity:
*
Latino
Non-Latino
Client's Preferred Method of Contact:
*
Cell Phone
Home Phone
Email
Please check ALL that apply:
Currently using public transportation
Veteran
First generation American (Were parents born outside of the United States?)
Formerly incarcerated
Does client currently have a job?
*
No
Yes - If YES, please complete the section below for Job 1 / Job 2
Job 1 - Employer:
Job 1 - Start Date:
-
Month
-
Day
Year
Date
Job 1 - Industry:
Job 1 - Please check all that apply:
Part-time
Full-time
Contract
Job 1 - Compensation:
Hourly
Salary
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:
-
Month
-
Day
Year
Date
Job 2 - Industry:
Job 2 - Please check all that apply:
Part-time
Full-time
Contract
Job 2 - Compensation:
Hourly
Salary
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:
*
Public Benefits
Coordinated Entry (A streamlined system providing quick access to individuals and families seeking assistance through a coordinated referral and housing placement process.)
Unemployed
Section 8
None of the above
Unknown
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.
*
Yes
No
PART 3: DRESS FOR SUCCESS
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?
PART 4: CAREER SERVICES / EmpowerHER
What is your goal for this program (Check all that apply).
Prepare to find a job
Prepare to find a better job
Improve or build my resume
Improve my interview skills
Assess my career path
Other
Do you own a computer?
Yes
No
Do you have easy access to a computer?
Yes
No
What type of job are you pursuing? (Select all that apply.)
Retail sales
Customer service
Administrative assistant
Medical or science related
Finance or banking
Education
Manufacturing
Construction
Technology
Food service
Housekeeping or hospitality
Other
What challenges do you think you need to overcome to be successfully employed? (Select all that apply)
Transportation
Childcare
Family obligations
Physical limitations
Technology
Career wardrobe
Other
How much time do you have to work on improving your job readiness skillset? (Select one)
1-2 hours per day
1-2 hours per week
1-2 hours per month
Do you have a resume?
yes
no
Signature of Client
*
Print
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