Nonprofit Partner Agency Referral Form

Nonprofit Partner Agency Referral Form — Form Fields

This nonprofit template includes 9 fields. Refer a client or community member to a partner agency for services your organization cannot provide. Free to customize and use on ZenBuild.

• Client Name (first name only or initials) (text, required)
• Client Consent to Share Information Obtained? (dropdown selection, required) — options: Yes - Written Consent, Yes - Verbal Consent, Not Applicable - Referral is Anonymous
• Referring Organization (text, required)
• Case Worker/Contact (text, required)
• Caseworker Email (email, required)
• Partner Agency Being Referred To (text, required)
• Service Needed (dropdown selection, required) — options: Housing, Food Assistance, Mental Health, Legal Aid, Employment, Medical Care, Transportation, Other
• Reason for referral and relevant background (long text, required)
• Client Contact Information (if consent given) (text, optional)