Partner Agency Referral Form

Please note: Harbor Connects will be closed from 12/24/24 to 01/01/25 and will not be reviewing applications during this time.

Date*

MonthDayYear

First and Last Name, Age, and Gender Identity of Adult Individual/Family Members*

If there are children, list names, ages and gender identities here

Individual's/Family's Address (If unhoused, please provide the city they currently reside in)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client Phone Number

Please enter a valid phone number.

Please provide information regarding why the individual/family needs support at this time.*

How much are you requesting? How will the funds be used?*

What are the individual's/family's sources of income including benefits?*

What is the plan for the individual/family moving forward? *

Is the individual or any member of the family a veteran?*

YesNo

Referring Contact's Name*

First NameLast Name

Referring Partner Organization*

Referring Contact's Phone Number*

Please enter a valid phone number.

Referring Contact's Email*

example@example.com

Referring Partner Agency's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you or your agency applied for assistance on behalf of this participant previously?*

YESNO

If YES, did the participant receive assistance?

YESNO

If YES, please explain when and what it was for.

File Upload: Please upload any supporting documentation related to this request. (ie. Copy of a lease; 3 day or quit notice; invoice for item/service being requested; copy of registration)

Please note: Harbor Connects will be closed from 12/24/24 to 01/01/25 and will not be reviewing applications during this time.