Emergency Assistance - Service Provider Referral

Emergency Assistance – Service Provider Referral

This form captures referral information need to consider a family for ilooklikeLOVE emergency diaper assistance.

"*" indicates required fields

Please check the requirement for Emergency Diaper Assistance met by your client:*

***If your client does not meet any of these requirements but still need inventory, they can participate in our Diaper Day events if they are WIC/SNAP eligible. Come out of this form and visit ilooklikelove.org/events for upcoming dates and locations.

YOUR INFORMATION

Please provide your information as the referrer.

Your Name*

Organization Name*

What is the name of your program and/or organization?

Your Title/Position*

What is your position or title at the organization?

Your Email Address*

Your Phone Number*

YOUR CLIENT'S INFORMATION

Please provide information for the client you are referring for assistance.

Client's Parental Status*

“My client is the biological parent.”

“My client is the legal guardian.”

“My client is the foster or adopted parent.”

Please indicate below the child’s relationship to your client. EMERGENCY DIAPER ASSISTANCE IS ONLY AVAILABLE TO BIOLOGICAL, FOSTER, ADOPTED, PARENTS OR LEGAL GUARDIANS. Documentation of parental status (for example, copy of birth certificate, court papers, etc…) may be required from client.

Is this person currently receiving services from your program or organization?*

Yes

Documentation showing their affiliation with your program or organization may be requested.

Client Name*

Client Date of Birth*

Client Email Address*

Client Phone Number*

Client Address of Residence (including zip code)*

Please describe your client's crisis that prompted this request.*

CHILD INFORMATION

If assistance is approved, your client may receive 100 diapers and other essentials per child for up to two children. Both diapers and pull-ups are available for approved emergency assistance cases only. Please provide the necessary information below to process each child’s donation.

Child Name*

Child Date of Birth*

Diaper Size for Child Receiving Diapers*

Select the diaper size needed for this child.

Child Name #2 (only if applicable)

Name of the 2nd child. Do not complete if there is only one child.

Child #2 Date of Birth (only if applicable)

Date of Birth for the 2nd child. Do not complete if there is only one child.

Diaper Size for Child #2 Receiving Diapers (only if applicable)

Select the diaper size needed for this child. Do not complete if there is only one child.

CONFIRMATION

By entering your first and last name below, you certify that the information provided in this referral is accurate. You also approve for ilooklikeLOVE to contact the potential client and referring agency contact via email or by phone to verify the information provided or to get additional information.

Phone

This field is for validation purposes and should be left unchanged.

Emergency Assistance – Service Provider Referral