Client Referral Form

Client Referral Process

To refer a client, please complete the referral form with their information. Our team will contact the client directly to schedule an appointment. For questions about our services, call (561) 249-3898 to speak with a team member.

Please Note:

Clients should notify us if they are running late or unable to attend their appointment.
For the safety and comfort of all, clients may not bring guests, including friends, partners, or children.
We respectfully request advance notice of the presence of a service animal so that we can attempt to accommodate staff, volunteers and other clients with allergies or other concerns.

Client Information

First Name *

Last Name *

Email *

Date of Birth *

Address Line 1 *

Address Line 2

Phone

City *

State *

Zip *

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.

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

Employment Status * The field Employment Status is required.

Emergency Contact Name The maximum length for the field Emergency Contact Name is 500 characters.

Emergency Contact Phone The field Emergency Contact Phone must be a phone number.

Mode of Transportation * The field Mode of Transportation is required.

Referral Information

Please provide the agency and case manager information here.

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

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

Case Manager Phone + Ext. * The field Case Manager Phone + Ext. is required.

Referral Agency * The field Referral Agency is required.

How did you hear about us? * The field How did you hear about us? is required.

Appointment Information

Please complete the following so we can best match your client to our services.

Please briefly describe the client’s needs, such as clothing for interviews or employment, or career services related to job readiness. * The field Please briefly describe the client’s needs, such as clothing for interviews or employment, or career services related to job readiness. 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 aware of guest and animal policy * The field Confirm client aware of guest and animal policy is required.