Agency Referral Form "*" indicates required fields Referring Agency (If you are an individual self-referring or referring a friend, put your name here):* Agency City (If you are an individual self-referring or referring a friend, put your city here):* Staff name (or referrer name; if self referring, leave blank): Staff email (or referrer email; if self referring, leave blank): Staff phone number (This can be an agency contact or you, yourself, if you are not an agency; if self referring, leave blank):What city is your referred person in?* First name* Last name* Applicant preferred language:*EnglishFrenchApplicant email:* Applicant phone number*Applicant is currently a client of nominating organization Yes Applicant is not a current client, but can access services from nominating organization Yes If currently a client, please provide the name of case/support worker: Case/support worker phone number:Applicant is 18 years of age or over:* Yes If not currently housed, please elaborate. (We will sometimes accept strong candidates who are still in the shelter. Note: Second stage housing is considered, for our purposes, housed.)Please briefly outline current housing situation: Applicant is currently employed in some way Yes Applicant is on social assistance Yes Please tell us a little more about why you feel the applicant would be a good fit for the program.*Does the client give consent for you to submit this information and for us to speak with you about this referral should we request more information? (Self-referrals: do you give consent? If referring a friend, please confirm consent to the above) Yes By completing this checklist, I confirm that I have verified information above. (Type in your full name as your digital signature.) Any questions? Write to us: contact@upwithwomen.org