Client Referral Form

*Please note: Enter the client's information first. There are fields below client information for referral agency and case manager contact info.

We are currently seeing clients on Tuesdays, Wednesdays, and Fridays between the hours of 11:00 am and 4:00 pm and on the 2nd and 4th Saturdays of the month from 10 am - 2 pm. Masks are still encouraged at this time.

You may contact us at (561)-249-3898 to schedule an appointment prior to submitting the referral form.

Please remind clients that for the safety of all involved, we cannot allow any guests (including friends, partners, or children) to accompany clients.
Please also remind clients to contact us if they will be running late or unable to make the appointment.

Thank you,

Dress for Success Palm Beaches

Client Referral Form

First Name *

Last Name *

Email *

Date of Birth *

Address Line 1 *

Address Line 2

Phone

City *

State *

Zip *

Referral Agency * The field Referral Agency is required.

Case Mgr Name - Phone - Email * The field Case Mgr Name - Phone - Email is required.

Case Manager Email * The field Case Manager Email is required.

Client Age * The numeric field Client Age is required.

Education * The field Education is required.

Is Client a Veteran? * The field Is Client a Veteran? is required.

Does Client Receive Public Assistance? * The field Does Client Receive Public Assistance? is required.

Marital Status * The field Marital Status is required.

Children? * The field Children? is required.

Number of Children * The numeric field Number of Children is required.

How many under 18 live with you? * The numeric field How many under 18 live with you? is required.

Race * The field Race is required.

Clothing Size * The field Clothing Size is required.

Shoe Size * The field Shoe Size is required.

Which DFS location would work best for a suiting? * The field Which DFS location would work best for a suiting? is required.

Confirm client is aware of no children policy * The field Confirm client is aware of no children policy is required.

Notes The maximum length for the field Notes is 500 characters.