Client Referral Form - Gifts of Love

The mission of Gifts of Love is to help meet the basic needs of individuals and families experiencing a temporary financial crisis. We provide food, clothing, household items, baby goods and furniture, at no charge, to our clients.

Regular clients who qualify to receive monthly assistance from Gifts of Love demonstrate their commitment to maintaining their independence through working full- or part-time or actively seeking work after an emergency or transitional situation (such as a divorce or loss of job). Gifts of Love services are provided in our offices in Avon, during regular office hours.

What town do you live in?*
First Name*
Last Name*
Email
Address*
Phone
Alternate Phone
Composition of Household:(Please include number of adults, children and ages of children):
Reason for Requesting Assistance:(Circle all that apply): Fire Health Loss of Job Change in Marital Status Low Income Other:

Type of support requested: Monthly support for food and/or clothing Other Needs:

If you are requesting monthly support, please provide the following additional information.
Please list employer, type of work, and average hours per week for all adults in household or if Client is in School please explain program:
If unemployed, list most recent employer and date of termination.
Please list other agencies you are accessing for support services:
Will the prospective client be receiving holiday gifts from another agency?
If yes, which one?
Gifts of Love provides temporary support for clients facing emergency of transitional situations. Please estimate how long you may need assistance:
For security reasons please enter result of 3 + 1 below: Answer *

Do you have a Social Worker or the equivalent who can fill out a referral form?
Please contact a social worker and have them fill out a referral form on your behalf. This can be a Social Worker that you are currently working with, a school Social Worker; Priest, Pastor, Rabbi, Etc. or a similar person who understands your circumstances. Please also note that you or someone in the household needs to be currently employed or in school to qualify for assistance from Gifts of Love.
Are you or someone in the household currently employed or in school?
Please bring referral form to your social worker or equivalent.
You or someone in the household needs to be currently employed or in school to qualify for assistance from Gifts of Love.