PLEASE COMPLETE THE FOLLOWING INTAKE FORM to add a family to xHope's Opportunities and Experiences list
PLEASE NOTE:
A referral by a partner organization, school employee or xHope is REQUIRED in order to be added to our "Invitation Only" list. All information provided is subject to verification.
CAREGIVER
*
First Name
Last Name
Please select those which apply:
*
Foster Parent (kinship and guardianship included)
Adoptive Parent
Single Parent
Newcomer/Refugee
Unhoused
Other
Caregiver E-mail
*
example@example.com
Caregiver Phone Number
*
-
Area Code
Phone Number
COUNTY of Residence
*
Please Select
SACRAMENTO
AMADOR
PLACER
EL DORADO
OTHER
REFERRED BY
*
Please Select
CASE MANAGER
SOCIAL WORKER
FAMILY LIAISON
FAMILY ADVOCATE
SCHOOL ADMIN/TEACHER
OTHER
Other:
Name
*
First Name
Last Name
ORGANIZATION or AGENCY Affiliation:
*
Referring Person E-mail
*
example@example.com
Referring Person Phone Number
*
-
Area Code
Phone Number
Number of children (under the age of 18) CURRENTLY in IMMEDIATE care:
*
Please Select
1
2
3
4
5
6
Child 1 Name:
*
Child 1 Gender:
*
Child 1 Age:
*
Child 2 Name:
*
Child 2 Gender:
*
Child 2 Age:
*
Child 3 Name:
*
Child 3 Gender:
*
Child 3 Age:
*
Child 4 Name:
*
Child 4 Gender:
*
Child 4 Age:
*
Child 5 Name:
*
Child 5 Gender:
*
Child 5 Age:
*
Child 6 Name:
*
Child 6 Gender:
*
Child 6 Age:
*
Select which of the following the family is being referred for (multiple selections allowed):
*
Add this family to xHope's Outreach Event Invite List
Send this caregiver the link to sign up for a Threads of Hope Shopping Experience
This family has a junior or senior who may be interested in mentorship/scholarship opportunities
This family may be interested in on-site enrichment classes and opportunities
Other
xHope is transitioning to in-person connection with families to receive resources and support, with the goal of building relationships. Does this family have reliable transportation?
*
Yes
No
If no, is the referring person able to assist in arranging transportation?
Yes
No
Please share any other additional information you'd like us to know.
THANK YOU for completing this request form.
Please note: After reviewing this submission, xHope staff will take the appropriate next steps to connect with the caregiver based on the resources needed. Please let the caregiver know that you referred them to our programs, and have them look for our communications via phone or email.
Submit
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