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

2. Referrer's name (that's you)*

   Please provide your first and last name

3. Your email and best phone number*

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

5. Your division*

   1. Child and Adult Protection Services
   2. Community and Child Support Services
   3. Finance Services
   4. Operations Services
   5. Legal Services
   6. Other

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

   1. Yes
   2. No

8. Name of client (head of household)*

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

10. Client's date of birth (head of household)*

11. client's best form of contact*

    Please provide and email or phone number

13. Client's secondary contact

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

14. Number of family members in the household*

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

16. Ages of children in the household, if applicable

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

17. Anyone in the household with special needs or pregnant?*

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

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

    1. Yes
    2. No

20. List the names and ages of all members in the household who are not lawful permanent residents.

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

    1. Living on the streets
    2. Couch surfing (family, relatives, acquaintances)
    3. Residing in a shelter or hotel/motel
    4. Other

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

    1. Food Assistance
    2. Medical Assistance
    3. Cash Assistance, TANF or Colorado Works
    4. Adult Financial
    5. Child Protection
    6. Adult Protection
    7. None

25. Notes:

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

Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field