You must be a qualified referring agent  (social worker or pastor) to submit this form. 

If you are in need of a referral you can check our list of participating churches for your church and then contact them for assistance....or contact your social worker.

 

INTAKE REFERRAL FORM
Love INC
PO Box 18517, Charlotte, NC  28218
P: 704-536-5588
F: 704:536-5338

 

Love INC-Charlotte
Love in the Name of Christ
 Date of Referral:

*Required Information
Client Name: 
 First*:  Middle: Last*:
Partner Name:  First:  Middle: Last:
Address*:    Apt #: 
City*:     State*:    Zip&:   Email:
Phone 1*:  Phone 2:
Emergency
Contact:
Name:
Relationship:
Phone:



CLIENT INFORMATION
PARTNER INFORMATION
SS#*:   SS#:
DOB*:   DOB:
Sex:
Male
Female
   Sex:
Male
Female
Ethnicity:
Cau
AA
NA
Hisp Asian Other
   Ethnicity:
Cau
AA
NA
Hisp Asian Other
Marital Status:
S M W
Div Sep CL
  Marital Status:
S M W
Div Sep CL
Total Adults in Household:
Total Children in Household: 
Names & DOBs of Children:

Service Requested (e.g. yard work, baby supplies, home repairs, etc):


Significant Information about Client  (Their Story):


Client's Primary Diagnosis*:


Partner's Primary Diagnosis (If applicable):



Has client or partner ever received help from Love INC?
Yes
No

What steps has the client or client's family taken or are willing to take to meet this need themselves?
Has your client requested a pastoral or lay visit?
Yes
No 
 If yes, from what church?


HOUSEHOLD FINANCIAL
INFORMATION
  
Does your client have...(check all that apply)
Residence:  Own    Rent
Medicaid: Yes No 
Veteran's Benefits: Yes No 
Medicare: Yes No 
HOUSEHOLD Monthly Income
Client SS/SSI: $
Partner SS/SSI: $  
Food Stamps: $
Has client been referred to any other agency
for this request or for a similar need?
Yes No 
Job Income: $
Agency:
Other Income: $
Contact:
Total Income: $
Phone:
   
Referred for:
   
ATTENTION:
You must complete the following section:
   
Yes, my client has provided documentation to prove ALL sources of household income.
   
No, my client has not provided documentation to prove ALL sources of household income.
           
           
   
Referring Agency or Church:
   
Referring Agent:
   
Phone:
   
Email:
           
           


Enter the letters shown in the graphic below in the adjacent box

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After you click submit, you will be taken to a confirmation page.
If not, please check over the form for highlighted items that are missing.