HOPE Ministries – Baton Rouge, LA

4643 Winbourne Ave., Baton Rouge, LA 70805 225.355.0702

Family Mentoring Program
Agency & Church Referral Form

Donate Now!

Client's Name:

Client's E-mail:

Client's Phone:

Marital status:

Single (including divorced or widowed)

Married or Partnered

Total number of persons in household:

Number of children under 18 in household:

Family is at-risk for homelessness because they...
Check all that apply.

have delinquent rent or mortgage payments.

have received an eviction notice.

are living with friends or relatives who have asked us to leave.

are living in transitional housing.

are living in FEMA housing.

Highest level of education client has achieved:

Less than high school

High school

Some college

Associate's degree

Bachelor's degree

Graduate degree

Client's employer:

Position or Job Title:

Number of months
on the job:

Hourly rate of pay:

Please fill out the following section about yourself,
the person making this referral.

Name:

Job Title:

Agency or Church:

E-mail address:

Phone number:

Thank you for filling out this referral form
for HOPE Ministries' Family Mentoring Program.
A representative from HOPE Ministries
will contact the client whom you are referring directly.
Please feel free to direct any additional inquiries
to Program Manager Jeffrey Fairley
at 225.355.0702 ext. 33.

Our Mission

Prevent homelessness.
Promote self-sufficiency
and dignity.

Please do not fill out this form
about yourself!
You may refer yourself to the
Family Mentoring Program
using this form.

Please read the enrollment criteria
for the Family Mentoring Program
before filling out this form,
to ensure that you are referring
a qualified client family.

If you would prefer to print a referral form
and submit it via fax or postal mail,
please feel free to do so.