COMMUNITY JUSTICE CENTER

REFERRAL FORM

FIRST NAME / MI :_____________________ GENDER: ______

LAST NAME: _________________________ AGE: ______

ADDRESS: ___________________________ BIRTHDATE: ___________

ADDRESS 2: _________________________ SS. NO: ________________

CITY: _______________________________

ZIP CODE: ___________________________

COUNTY: ____________________________ EMAIL: ________________

PHONE: ______________________________

REFERRAL SOURCE: (How did you hear about us?)

ANNUAL HOUSEHOLD INCOME: $

Check if applicable and insert monthly amount:

TANF___ GA____ SSI____ Food Stamps____ Other____

NUMBER OF PERSONS IN HOUSEHOLD:

DISABILITY CATEGORY:

1. PHYSICAL 5. LEARNING

2. MENTAL HEALTH 6. DEVELOPMENTAL

3. VISUAL 7. HIV/AIDS

4. HEARING 8. MULTIPLE

DISABILITY SOURCE:

1. FROM BIRTH 5. ELDERLY

2. WORK-RELATED 6. UNKNOWN

3. ACCIDENT-RELATED 7. OTHER

4. COMBAT-RELATED

DISABILITY SPECIFIC: (Please list specific complaints or ailments.)

PRESENTING ISSUES: (What are you seeking?)

Our offices are located on the Third Floor. We also have seeing eye dog at the office. Does either of these pose a problem for you? Would you require a home visit?