Focus on Home Client Referral Form
Sometimes a suitable home is all that stands between the reunification of a family; other times it is an important step toward a more stable family life. 

This is why Focus on Home is committed to helping families integrate into a healthy family lifestyle. We work closely with partnering agencies to identify clients working to achieve self-sufficiency but who need help obtaining basic necessities, such as furniture and dishes, to create a suitable home for themselves and their families.

Each referral application will be review and if approved, FOH will work directly with them to create a personalized home environment based on their specific needs. Providing donated, gently used furniture, housewares, and decor, Focus on Home volunteers will set up the new home environments, allowing families to direct their energy, time and resources into creating a positive future.
Let's start by getting some quick information about your agency. Ready?

Referral Agency Information

let's collect some quick info about your agency...
What's your first name? *

Hey {{answer_24038934}}, nice to meet you.

What is your last name?

What is a good number to reach you?

Your Agency's Work Address

Thanks! Now we just need some information about the family you are referring.

Family Information

This section will give us some basic info regarding the family being referred.
Name(s) of Referral


How long have you know/worked with this client?

Children in Household (1st Child)

Child's Name

Child's Age

Child's Sex

Children in Household (2nd Child)

Child's Name

Child's Age

Child's Sex

Children in Household (3rd Child)

Child's Name

Child's Age

Child's Sex

Children in Household (4th Child)

Child's Name

Child's Age

Child's Sex

Do the children currently live with the client?

If not, describe the custody situation and when/if the children will live with the client:

Are there barriers to reunification related to the home?

If yes, please describe...

Housing Situation

What is the client’s housing situation?

Are they on a Section 8 voucher?

Is anyone else living in the household with the family? If so who?

Does the family currently have any furniture or beds?

Work Information

Is the Client currently employed?

Place of Employment

Type of Employment

If not employed does the client have another source of income?

Almost done! These last two question will really help us determine if the family being referred is a good fit for Focus on Home services so please take a moment to answer these questions fully.

History of family and current status of treatment plan: *

There are many families in need who are working hard to become self-sufficient and stay together. Please describe why you believe this client will use our help to provide a healthy, stablefamily environment. *

Great! We review applications twice a month - on the 5th and 20th (if falls on weekend, first workday after).

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