Agency Referral Form
Instructions for using this form
Please complete as many form questions as possible. It is important to have the correct address for clients as delivery is made directly to the client at their home (client’s cannot pick-up items from our office). It is also important to verify that the client has a photo ID (expired okay) at the time of delivery.
After receiving a partner referral, Parts of Peace will contact the client directly for any additional information needed. All clients and case managers will receive notice of application decision via email the same or next business day.
Clients can only receive assistance once a year. Extenuating circumstances may be considered by emailing email@example.com with subject “Extenuating Circumstances“
Clients must make themselves available for their chosen delivery date and time. Typically we are unable to do re-schedules except in cases of inclement weather.