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.   You may also call Mecklenburg County's "Just One Call" referral service at 704-432-1111 if your church is not listed.

 

INTAKE REFERRAL FORM
Love INC
PO Box 18517, Charlotte, NC  28218
P: 704-536-5588
F: 704:631-9424

 


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

*Required Information

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



PRIMARY CLIENT INFORMATION
FINANCIAL INFORMATION
DOCUMENTATION ATTACHED
SS#*:
Client SS/SSI:
DOB*:
Food Stamps:
Sex:
Male
Female
Job Income:
Ethnicity:
Cau
AA
NA
Hisp Asian Other
Other Income:
Marital Status:
S M W
Div Sep CL
Total Income

Total Adults in Household:    Provide information for each additional adult below
Name DOB SSN# STATUS TOTAL INCOME INCOME SOURCE
Total Children in Household:    Provide name and birthdate of each child
Name DOB
GENDER
  Name DOB
GENDER
 
If expecting, what is your due date: What is the sex of your unborn child?   

CLIENT PROFILE

Does your client have...(check all that apply)
Has client or partner ever received help from Love INC?

Yes
No

If yes, what year?:

Medicaid: Yes No 
Veteran's Benefits: Yes No 
Medicare: Yes No 

Has your client requested a pastoral or lay visit? Yes
No 
Has client been referred to any other agency
for this request or for a similar need?
Yes No 
If yes, from what church?
Name of Agency:
What steps has the client or client's family taken or are willing to take to meet this need themselves?

 

Contact:
Significant Information about Client  (Their Story):
Phone:
Need Served
Client's Primary Diagnosis*:
Date Served

CLIENT NEEDS

NEEDED?
ITEM DESCRIBE NEED

Baby Layette Need expected, DOB and Gender
Handrails-Exterior Door Location / No of Steps
Max 4
Home Repairs - Exterior Describe Need
Home Repairs - Interior Describe Need
Telephone Reassurance Describe Need
Pastoral/ Ministerial Staff Visit Describe Need
Wheelchair Ramp - exterior Door Location / No of Steps
Max 4
Computer Ministry Describe computer issue.
Cleaning Describe Need
Toiletries Delivery
Transportation

This service can only be used, at the most, once/month and only for doctor appointments. 14 days minimum advanced notice is required for current clients and 28 days minimum is required for new clients.

Food Referral Delivery. Other sources referred to?
Moving Assistance Describe items to be moved and give From and To Addresses
Other Provide Details

REFERRING AGENT INFORMATION

ATTENTION:
You must complete the following section:
Yes  No
Has client has provided documentation to prove ALL sources of household income.
Referring Agency or Church
Referring Agent*:
Phone:
YOUR Email*

PLEASE INCLUDE ALL INCOME CONFIRMATION DOCUMENTATION

(click browse to locate supporting documents you have saved on your computer)

_______________________________________

Enter Security Code

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.