Focus on Home Client Referral Application
Sometimes a suitable home is all that stands between the reunification of a family; other times it is an important step toward a more stable family life. This is why Focus on Home is committed to helping families integrate into a healthy family lifestyle. We work closely with partnering agencies to identify clients working to achieve self-sufficiency but who need help obtaining basic necessities, such as furniture and dishes, to create a suitable home for themselves and their families. Each referral application will be review and if approved, FOH will work directly with them to create a personalized home environment based on their specific needs. Providing donated, gently used furniture, housewares, and decor, Focus on Home volunteers will set up the new home environments, allowing families to direct their energy, time and resources into creating a positive future.
Referral Agency Information
Let's collect some quick information about your agency.
Referral Agency
*
Hope House OKC
ReMerge
Palomar Family Justice Center
YWCA of OKC
Positive Tomorrows
Catholic Charities
Pivot
Sisu
OKCPS
DHS
Homeless Alliance
City Rescue Mission
Sunbeam Family Services
Diversion Hub
Restore OKC
Red Rock Behavioral Health
Northcare
Hope Community Services
Veterans Administration
Leah's Hope
Other
If other, please list agency name here:
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Your Phone Number
*
-
Area Code
Phone Number
Agency Work Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Family Information
This section will give us some basic info regarding the family being referred.
Name of Referral
*
First Name
Last Name
Age of Client
20 or under
21 - 30
31 - 40
41 - 50
51 - 60
60+
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race Identification of Client
Native American
Asian
Black or African American
White
Other
If Native American, what tribe?
Is Client Hispanic, Latino or Spanish origin?
Yes
No
Is the Client a refugee?
Yes
No
If yes, what is country of origin?
How Long Have You Known/Worked With this Client?
*
Is there an open DHS case?
*
Yes
No
Not currently, but there has been one for this family in the past.
Children in the Household's Information
How many children are in the household?
n/a
1
2
3
4
5
6
7
8
9
10
11
12
Child #1 Name
Child #1 Age
Child #1's Sex
Male
Female
Child #2 Name
Child #2 Age
Child #2's Sex
Male
Female
Child #3 Name
Child #3 Age
Child #3's Sex
Male
Female
Child #4 Name
Child #4 Age
Child #4's Sex
Male
Female
Child #5 Name
Child #5 Age
Child #5's Sex
Male
Female
Child #6 Name
Child #6 Age
Child #6's Sex
Male
Female
Child #7 Name
Child #7 Age
Child #7's Sex
Male
Female
Child #8 Name
Child #8 Age
Child #8's Sex
Male
Female
Child #9 Name
Child #9 Age
Child #9's Sex
Male
Female
Child #10 Name
Child #10 Age
Child #10's Sex
Male
Female
Child #11 Name
Child #11 Age
Child #11's Sex
Male
Female
Child #12 Name
Child #12 Age
Child #12's Sex
Male
Female
Do the children currently live with the client?
Yes
No
If not, describe the custody situation and when/if the children will live with the client:
Are there barriers to reunification related to the home?
Yes
No
If yes, please describe...
Housing Information
What is the client’s housing situation?
*
Rent
Own
Are they on a Section 8 voucher?
*
Yes
No
Is anyone else living in the household with the family?
*
Yes
No
If so, who?
*
Does the family currently have any furniture or beds?
*
Yes
No
List items the family currently has in their possession.
*
Work and Military Information
Is the Client currently employed?
*
Yes
No
Place of Employment?
*
Type of Employment?
*
Part Time
Full TIme
If not employed, does the client have another source of income?
*
Has Client served in the U.S. Military?
Active
Retired
Reserve
National Guard
If yes, what branch?
Army
Marines
Air Force
Navy
Coast Guard
Referral Status
History of family and current status of treatment plan:
*
There are many families in need who are working hard to become self-sufficient and stay together. Please describe why you believe this client will use our help to provide a healthy, stable family environment.
*
Great! Thank you!
We review applications twice a month - on the 5th and 20th (if it falls on weekend, first workday after).
Please verify that you are human
*
Submit
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