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CARES Funding Program for hotel/motel vouchers - client referral form

  1. Please provide your first and last name

  2. If you are working remotely, please provide a phone number to reach your directly.

  3. Your division*

  4. Is the individual/family you are referring physically at CentrePoint Plaza or Arapahoe Plaza?*

  5. Please provide correct spelling of his/her legal first and last name.

  6. Please provide and email or phone number

  7. Optional: please provide and email or phone number of friend or relative they currently is in contact with in case their primary contact fails.

  8. This will help determine how many people need hotel/motel vouchers

  9. This will help determine what additional services the family may need.

  10. Please type in yes or no. If yes, please explain

  11. Is every member of the household a lawful permanent resident? If yes, skip the next question.*

  12. How is this individual or family experiencing homelessness?*

  13. What services is this individual or family receiving?*

  14. Please provide any further information that you feel is important to disclose at this time.

  15. Leave This Blank:

  16. This field is not part of the form submission.