Mission Of Deeds Client Referral Form

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Mission of Deeds, Inc.
OFFICE USE ONLY
Date Received: __________
6 Chapin Avenue, Reading, MA 01867
Initials: ________________
Tel: 781-944-9797 Fax: 781-944-7697
CLIENT REFERRAL FORM
CLIENT INFORMATION - SERVICING MIDDLESEX AND ESSEX COUNTIES
Client Name:
Date of Birth:
Gender:
Race (optional): American Indian or Alaska Native
Hispanic or Latino
Asian
White or Caucasian
Black or African American
Native Hawaiian or Other Pacific Islander
Other (specify)
Client Address:
Town:
State:
Zip Code:
Phone:
Alternate Phone:
List the names and ages of all other adults and children living in the home.
Name
Age
Gender
Name
Age
Gender
_______________________________
__________
_______________________________
_________
_______________________________
__________
_______________________________
_________
_______________________________
__________
_______________________________
_________
AGENCY INFORMATION
Referring Agency Name:
Agency Address:
City/Town:
State:
Zip Code:
Phone:
Extension:
Alternate Phone:
Name of Caseworker:
Email Address:
Date of Home Visit:
Caseworker’s Initials:
Has this client ever been serviced by Mission of Deeds?
yes
no
If yes, when:
Is this client currently scheduled to receive furniture from any other charitable organization? yes
no
Caseworker’s Initials:
Reason for Service (Check All That Apply): Disabled/ Illness
Elderly
Homelessness
Domestic Violence
Veteran
Low Income
Natural Disaster
Bed-Bugs
Other
Explain why there is a need:
Furniture Needs: (We will do our best to meet all requests. However, we cannot guarantee all requested items will be available on the day of the client’s
appointment.)
CLIENT RESPONSIBILITIES
• CLIENT MUST CALL 781-944-9797 to schedule an appointment after this form is faxed to MOD.
• There will be no rescheduling of missed appointments.
• Client provides truck (ONE TRIP ONLY). Client should bring help for loading truck.
• Client must be on time for appointment. Late arrivals may not be serviced.
• If needed, client should bring translator.
OFFICE USE ONLY
• Clients eligible for service one time only.
Date of Appointment:
Caseworker Signature: ____________________________ Date: ________
Client Signature: _________________________________ Date: ________
Time of Appointment:
Revised October 31, 2013

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