REFER CLIENT

Referral Form

Refer Client to Crossover Outreach

Client Information

First Name*
Last Name*
Phone Number*
Birthdate*
Email
Address of Residence*
City*
State*
Zipcode*
Gender*
Ethnicity*

Race*
No. of people in the household*
No. of adults*
No. of children*
Which program do you participate in

Insurance Carrier*

Need Help With: (must check at least one) *

Food
Clothing
Household
Personals
Cleaning Supplies
Diapers
Bus Pass

URGENT: PLEASE SHARE WITH YOUR CLIENT THAT THEY MUST BRING PICTURE ID, PROOF OF NUMBER OF PERSONS IN HOUSEHOLD, AND DOCUMENTATION SHOWING CHILDREN LIVE IN THE HOME OF THE PARENT SEEKING ASSISTANCE. These items are REQUIRED to obtain services! We will also check our records. If it is not time for them to come, we will not be able to provide service.

NOTE: Food and Personals are available once every 30 days, Clothing and Cleaning Supplies are available once every 60 days. Household is a one-time service requiring proof of lease showing move in last 30 days. Household is intended to help someone begin a new home with the basics.

Once you submit this referral, there is a link on the THANK YOU page to download our Client Services and Hours sheet providing details on all services provided and when. PLEASE TAKE A MOMENT TO DOWNLOAD AND REVIEW THE SHEET. Feel free to call us with any questions at 810-234-2479. Thank you!

Agent Information

Referral Agency*
Agents Name*
Agents phone number*
Agents email*
Comments:

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Crossover Outreach
414 W. Court Street
Flint, MI 48503
Phone: 810-234-2479
Email: [email protected]

*donations are accepted TUESday through Friday from 9am - 3pm - Limit (4) bags or boxes per vehicle please.

*daily services are available Tuesday through friday from 10am - 2:30pm

*closed mondays

Crossover Outreach

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Crossover outreach is an equal opportunity provider