Recipient Referral
Thank you for taking time to complete this application to Step Onward Foundation. Please provide as much information as possible, as it will help our committee make an informed decision in a timely manner. Step Onward does NOT use this information to determine eligibility for services, nor do we discriminate based on age, race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, disability or genetic information.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Completed By
*
Title
Organization
*
Dell Children's Hospital
Lifeworks
Presbyterian Children's Home
Depelchin
Star of Hope
Champion Institute
Other
Department (if appropriate)
Phone Number
Format: (000) 000-0000.
Extension
Email
example@example.com
Back
Next
Please enter the recipient information below. Recipients are generally students or patients receiving care at a local hospital.
Recipient Name (Patient, Student etc)
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Caregiver Name (if the recipient named above is under 18)
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to Recipient
How long have you been working with this recipient?
How did you come to know this recipient?
Are you or someone you know related to this recipient?
Yes
No
Known Recipient History
Criminal History
Addiction History
Other
What is the anticipated need for this recipient? Please also include the reason for your referral.
*
Anticipated Need
*
One-time request for financial assistance
Short-term financial assistance (1-2 months)
Long-term financial assistance (2+ months)
Other
Is this individual or family experiencing a short-term setback (i.e. job or wage loss, hospitalization of a child etc) where short-term financial assistance would allow them the time needed to get back on their feet? Please elaborate.
*
What resources, if applicable, have you already provided to this family?
What is the reason for this referral?
Support recommended for (check all that apply)
Housing
Education
Mental Health
Food Security
Physical Health
Transportation
Urgent
Recommended Amount
Date Needed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Please share details on the expenses that make up this amount
Include what each bill is and how much. This total should equal the total amount requested.
What is your perception of how this recipient is doing and general state of mind? Please include any pertinent information on their ability to achieve financial independence after short term support.
*
Please add any additional history or information on the current situation
Additional comments or anything else we should know
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