The University Church Toledo

1

Please use our online referral form and one of our Community Health Workers will reach out to you soon [within 48 busisness hours]. Please answer questions truthfully, as they are ONLY used to help connect you with resources.

2

Name* This field is required.

First Name

Last Name

3

Date of birth* This field is required.

4

Current address or where you receive mail.

5

Phone Number (If you don't have your own someones close to you we can use to get a hold of you will suffice) (personal information will not be discussed)* This field is required.

6

E-mail

example@example.com

7

Date of referral

8

Are you pregnant?* This field is required.

YES

NO

9

Do you have any children two or under in the home with you?

YES

NO

10

Are there any children under 18 in the home?

YESNO

11

Are you in need of assistance with finding clothing or other items?

YES

NO

12

Are you in need of assistance with finding resources that have food?

YES

NO

13

Are you in need of assitance with transportation?

YES

NO

14

How did you hear about us?* This field is required.

15

Do you consent to be contacted by a University Church Community Health Worker by phone?

YES I AGREE

NO

16

OPTIONAL: To better help understand your needs please briefly tell us a little bit about your expectations for this program? In other words what can we help you with

17

Disclaimer; please note that we are a resource only and we do not gurantee housing, transportation or food but we will try our best!