Client Referral Form - Dress For Success Dallas printable pdf download

CLIENT REFERRAL FORM

Agency contact must fax to or email this completed form to Dress for Success Dallas no later than 5 days prior to appointment.

AGENCY INFORMATION

Program/Agency: ____________________________________ Contact Name: __________________________________

Telephone: _________________________ Ext: _______ Email: ______________________________________________

CLIENT INFORMATION

Client Name: ____________________________________________________ Date of Birth: ________________________

Address: ________________________________________ City: _______________ State: _____________ Zip: _________

Telephone: (____) _______________________________ Email: _______________________________________________

Emergency Contact: ___________________________________ Telephone: _____________________________________

Housing Status:

___Rent ___Section 8 ___Homeless/Shelter ___Homeowner ___Group Home ___Work Release ___Live with Relative

Ethnicity:

___American Indian ___Asian ___African American ___White ___ Hispanic or Latina Other ___________________________

Marital Status:

___ Single ___ Married ___ Divorced/Separated ___ Widowed

Education Level:

___Some High School ___High School Graduate ___GED ___Some College ___College Graduate/Degree ____________

Have you served in the Military: ___ Yes ___No

Type of Suiting: ___Interview ___ Employment

Suit Size: ______ Shoe Size: ______ Bra Size: _______

Do you have a completed resume? ___ Yes ___No

If so, please bring a copy with you to your appointment.

Potential Employer for Interview Suit: ________________________ Position: ______________ Interview Date: ________

Employer for Employment Suit: _______________________________________ Position: __________________________

SPECIAL STATISTICS

(please check one)

Are you: ___ Homeless ___ Veteran ___ Immigrant ___ Refugee ___ Disabled ___ Incarcerated

Age Group: ___ 18 to 24 ___25 to 39 ___ 40 to 60 ___ 60-plus

Mode of Transportation: ___Bus ___Car ___Taxi ___Bike ___MetroAccess

Have you previously been a client of Dress for Success Dallas? ___ Yes ___ No When? __________________________

Are you a military Veteran? ___ Yes ___ No

Are you enrolled in: Health Insurance ___ Yes ___ No

Medicaid ___ Yes ___ No CHIPS: ___ Yes

Have you ever been a victim of domestic violence? ___ Yes ___ No

rev 2/12/17

Client Referral Form - Dress For Success Dallas