Please fill out all applicable fields.  Required fields are marked with a red asterisk.  Please do not include any personal medical information or any financial information such as credit card numbers, bank account numbers, etc…  If you have any questions or have issues with the form or website, please contact us here or call 406-256-7304.  Thank you!

DATABASE - Client Detail/Referral

Referral Agency Information

Agency Name *

Contact Name *

Contact Email Address *

Contact Phone Number *

Client Information

Client First Name *

Client Last Name *

Client Phone Number *

Client Email Address

Client Mailing Address *

City *

State *

Zip Code *

Client Date of Birth *

Receiving Assistance? * YesNo

Marital Status * SingleMarriedDivorcedSeparated

Number of Children *

Level of Education *

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

GED

Some College

2 Year Degree

4 Year Degree

Masters Degree

Unreported

Ethnicity *

Native American

Caucasian

African American

Latina

Hispanic

Unreported

OtherOther

Household Income *

$0 - $15,000

$15,001 - $25,000

$25,001 - $35,000

$35,001+

Unreported

Information from the following two questions (convicted of a felony and served in the military) is collected for grant reporting purposes only

Has the Client Ever Been Convicted of a Felony? *

Yes

No

Unreported

Has the client served in the military? *

Yes

No

Unreported

Type of Work Desired *

Clothing Size

If you are unaware of the client’s clothing size, please note so.

Top *

Bottom *

Shoe Size *

Bra Size *

Would the Client Like to be Referred for a Haircut? *

Yes

No

Would you be willing to have your photo featured on our social media pages? *

Yes

No

Does the Client Require Additional Services? *

Not Interested

Resume Writing

Interview Skills

Online Certifications

Job Search Assistance

Professional Development

Basic Word

Basic Excel

Intermediate/Advanced Computer Classes

Financial Education

Health and Wellness

Hobby

OtherOther

Check all that apply.

Employment Information

Name of Employer

Position

Date of Upcoming Interview

or Employment Start Date

Starting Salary

Post-DFS Salary

Additional Comments

End of Referral Form

Career Center Notes

Career Center Notes

Career Center Services Performed

Resume

Cover Letter

Interview Skills

Job Searching

Robert Half

Setup Email

Computer Training

Workshop

Mentoring

Computer Lab

Virtual Services

Is this client actively using Career Services? YesNo

Client has utilized career services YesNo

Year client used career services

Did this client have an interview(s)? If so, when and where?

Is this client currently employed? YesNo

Has this client lost their job? YesNo

Interview Suiting

The fields below are the allowable items during the interview suiting. Please fill out all that apply. Where applicable, include color and size of each item.

Non-Slip Shoes?

Yes

No

Employment Suiting

Include size and color for each garment.

Non-Slip Shoes?

Yes

No

Important Note:

If client did not receive interview suiting, they may have these additional items as time permits

30 Day Suiting

Please fill out all that apply. Where applicable, include color and size of each item.

Date of 30 Day Suiting

30 Day Suiting Information

If you are human, leave this field blank.

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