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Referral Application Link

Please call 2-1-1 and visit https://www.crisiscenter.com/ for additional local resources if you are not currently working with a nonprofit, law enforcement officer or case manager.

Referral Application

Agency that is making a referral*
Name of Case Manager*
First Last
Phone Number of Case Manager*
Email of Case Manager*
Applicant Photo ID*
*All information below on application should reflect information on individual applying for Hands Across the Bay assistance*
Applicant Full Name*
First Name Middle Name Last Name Suffix
Applicant Date of Birth*
Applicant Address*
Street Address Address Line 2 City State ZIP Code
Applicant Phone Number*
Applicant Email Address*
Please list Applicants household member names and date of birth.*
*Please include adults & children*
Is the Applicant currently employed?*
- Yes
- No
Please explain why you are currently unemployed.*
Please upload the applicants most recent pay stub
Drop files here or
Accepted file types: jpg, jpeg, png, pdf.
What type of assistance is your client in need of?*
- Utility Assistance
- Transportation
- Visit to Donation Center(Items include hygiene, kitchen supplies, bedding, cleaning supplies, clothing, etc.)
- DV Safety Assistance
- Child & baby needs
- Advice/resources
- Grocery Assistance
- School Supplies
- Clothing
- Other
Select All that Apply
Please explain the circumstances surrounding the request for assistance.*
Does the applicant receive food stamps?*
- Yes
- No
- I have applied recently and am still waiting to hear back.
How much does the applicant receive per month?*
Enter USD
Is the Department of Children and Families (DCF) involved?*
- Yes
- No
Please give the name and phone number of your case worker.
Do you receive WIC (Woman, Infants & Children)?*
- Yes
- No
Do you receive housing assistance (ex: HUD, Section 8, etc.)?*
- Yes
- No
Have you or anyone in your household ever been arrested, convicted of or plead guilty to a crime?*
- Yes
- No
To help us evaluate your application, please describe the nature of the crime and your subsequent rehabilitation.*
Do you have a car/reliable transportation?*
- Yes
- No
Total Household Monthly Income*
Include all job-related income, social security, cash assistance, and child support.
Total Monthly Expenses
Remaining Funds After Expenses
*Bank Statements required upon request. This is so we can make sure there is no unnecessary spending*
I agree upon my final approval of services to provide supporting documentation for the circumstances at hand in relation to my request for assistance.*
- Yes
- No
Application Statement: I have read and fully understand the questions asked in this application. I certify that all of the answers I have given are true, accurate, and complete. I unerstand that the omission and/or misrepresentation of any fact from or on this questionnaire will result in immediate rejection of my application. Unless I noted otherwise, I authorize Hands Across the Bay to contact all of my personal references and do a criminal background check. If assisted, I agree to abide by all rules and regulations of Hands Across the Bay. I understand and agree that nothing in this application shall constitute an offer, a contract, or a guarantee of assistance. I understand that any decision is contingent upon my successful completion of all of the Company's lawful pre-assistance checks, which may include a background check. I agree to execute any consent forms necessary for the Company to conduct its lawful pre-assistance checks. By signing below, I agree to all of the terms stated here.
Signature*
Date of Application*
MM
DD
YYYY
Consent
I agree to the privacy policy.

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