Referral Incentive Program Form

Referral Incentive Program Form
Referrer's Information
Full Name*

First NameLast Name
Phone Number*
Email Address*
example@example.com
Relationship to AFLH (e.g., Caseworker, Family Member, Community Organization)*
Resident Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email Address*
example@example.com
Referral Details
Referral Details:Type of Care Needed (e.g., Mental Health Support, Senior Care, etc.)*
Specific Medical Conditions or Diagnoses (if known)
Does the Resident Require Assistance with Medication?*

YesNo
Additional Notes or Special Considerations*
Referral Incentive Program Details
Preferred Incentive*

Referral BonusDiscounted Stay at AFLH Short-Term Rental Homes
Next Steps
Preferred Contact Method:*

PhoneEmail
Best Time to Contact*
Terms & Conditions:

Incentives are awarded after the referred resident is approved and successfully moves into AFLH Group Homes.

The referrer must provide accurate information to qualify for the incentive.
AFLH Group Homes reserves the right to verify all referral details before issuing incentives.

For any questions or assistance with the referral process, please contact us at (614) 808-1011 / (614) 706-7388 or email us at info@aflh.org.
Should be Empty:

Referrer's Information