Case Workers Referral Form
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FOR USE BY SOCIAL WORKERS
INSTRUCTIONS: Please read the WeAreAlive™ 'Assistance' page on this website for guidelines. A complete and valid application under the guidelines saves time for everyone and helps to provide assistance to recipients faster. Print this form and complete. Please print clearly. Attach
the WeAreAlive™ "Request For Assistance & Release" form completed and signed by the client with the attachments required on that form. That form is available by clicking on the link for that form name at the end of this page. Please submit the entire package at one time in the order as requested on this form and the 'Request For Assistance' form. Methods to submit the documentation is listed on the 'Request For Assitance' form. Please email any questions to requests@WeAreAlive.org.
TO: We Are Alive, Inc. DATE:___/___/___ (month/date/year)
FROM: (Agency Name):________________________________________
Social Worker:________________________________________________
Address:_____________________________________________________
City:_____________________________ State:_________ Zip:_________
Phone Number:(____)____-______ Extension #:______
Cell Phone:(____)____-______ Pager:(____)____-______
Fax #:(____)____-______ Work Hours: ______ to ______
Email Address:______________________@______________________
THE FOLLOWING CLIENT IS BEING REFERRED TO WE ARE ALIVE:
Client Name: Last:____________________ First:____________________
Social Security #:____-____-_______
For:________________________________________________________
____________________________________________________________
BASIS AND REASON FOR REFERRAL FROM YOUR AGENCY:
As discussed on this website, WeAreAlive™ strives to raise non-restricted funds to assist recipients when assistance from standard programs is not available. Therefor it is important to WeAreAlive™ to know where you have already tried to get assistance for the recipient. Please attach any such requests made to other sources and denials from those sources. Please make sure the information submitted includes; 1)from whom assistance was requested, 2)when it was requested, 3)what was assistance requested for, 4)why the request was denied and 5)the agency contact person and phone number, should WeAreAlive™ need additional information from that agency.
CHECK LIST FOR ATTACHMENTS:
_¯The WeAreAlive™ "Request For Assistance And Release", signed by the client, with the attachments required on that form.
_¯Requests and denials for assistance from other agencies as requested above.
_¯Information to accompany the WeAreAlive™ "Request For Assistance &
Release" form submitted prior to this.
_¯Additional information requested by WeAreAlive™.
_¯Other:____________________________________________________
COMMENTS: (Attach Additional Sheet If Necessary.)
____________________________________________________________
____________________________________________________________
SOCIAL WORKER'S SIGNATURE: X__________________________
Click Here For "Request For Assistance & Release" Form! (V.110101.A.)
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