Community Resource Referral Form

Community Resource Referral Form — Form Fields

This nonprofit template includes 11 fields. Refer a community member to appropriate social services, food assistance, housing, or other resources. Free to customize and use on ZenBuild.

• Referring Staff or Volunteer Name (text, required)
• Staff Email (email, required)
• Client First Name (text, required)
• Client Last Name (text, optional)
• Client Phone Number (text, optional)
• Primary Need (dropdown selection, required) — options: Food assistance, Housing, Healthcare, Employment, Mental health, Childcare, Legal aid, Transportation, Other
• Additional Needs (checkboxes, optional) — options: Clothing, Utility assistance, Financial counseling, Substance use support, Senior services
• Summary of Situation (long text, required)
• Referred Organization or Agency (text, required)
• Client consented to this referral? (multiple choice, required) — options: Yes, No
• Follow-Up Notes (long text, optional)