Positive Alternatives & Outcomes NFP Community Support Referral Form

Referral Information

If you are a referral source please include your information here, if you are applying for self, please list your name as the individual.
Referring Agency or Individual Name*
Organization
Role/Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
If Other, please specify
Head of Household Information
Head of Household Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Total Number in Household*
Names & Ages of All Household Members
Type of Assistance Requested

Please submit one application per household within a 90 day period.
What type of assistance is your priority need at this time?

Clothing Closet (Business Casual, Everyday, or Seasonal Wear)Food Basket / Pantry SupportUtility Assistance (Electric, Water, Gas, etc.)Adopt-A-Kid / Holiday Gift SupportOther (please specify)
Assistance Details
If “Adopt-A-Kid / Holiday Gift” is selected:
Child(ren) Name:
Age:
Gender: 
Top 3 Gift Wishes (under $50 each): 
Clothing Size (if applicable): 


If “Clothing Closet” is selected:
Items Needed (☐ Adult ☐ Youth ☐ Infant)
Clothing Sizes
Type of Clothing (☐ Everyday ☐ Business Attire ☐ Winter Gear ☐ School Wear)



If “Food Basket / Pantry” is selected:
Number of Adults: 
Number of Children:
Dietary Restrictions or Allergies:
If “Utility Assistance” is selected:
Utility Type (☐ Electric ☐ Water ☐ Gas ☐ Other)
Utility Company Name: 
Account Holder Name: 
Past Due Amount (optional):
Upload Most Recent Bill (Utility Assistance)

Cancelof
Household & Financial Information
Monthly Household Income
Sources of Income

EmploymentTANFFinancial AidSSI/SSDIUnemploymentNone
Upload Proof of Income or Verification Letter (Optional)

Cancelof
Current Hardship Description
Eligibility and Acknowledgment

I understand that submission of this form does not guarantee assistance. Positive Alternatives & Outcomes NFP will review referrals based on need and available resources.
Please confirm:

The household resides in Hampton, VirginiaThe family is currently experiencing financial or resource hardship.This family is open to receiving non-monetary resources such as mental health referrals, parenting classes and educational resources for age-appropriate children.All information provided is true and accurate
Electronic Signature*
Date*

MonthDayYear
Date
Should be Empty:

Referral Information

Head of Household Information

Type of Assistance Requested

Assistance Details

Household & Financial Information

Eligibility and Acknowledgment