Basic Program Family Referral Basic Program Referral **IMPORTANT** Please note, assistance is not guaranteed. If your referral is approved, we will schedule delivery within 30 calendar days. A team member will call to confirm the delivery appointment. Please ensure you scroll all the way to the bottom of this page and click the purple "submit" button when your referral is complete. Thank you! Referral Partner Code # (5 digits) * if you do not know your code, please email office@ohaat.org Organization Representative * Representative Phone (10 digits only please) * Representative Email Address * **CAREGIVER DETAILS** Please enter as much information as possible. Caregiver's Full Name * Caregiver's Phone Country (###) ### #### Caregiver's Email * Is Caregiver a Non-English Speaker? Yes No Caregiver's preferred language Caregiver's preferred mode of communication Call Text Email Caregiver's Street Address Caregiver's City * Caregiver's Zip Code * Number of Adults (age 18 and older) in the Household * Number of Children (age 0 to 17) in the Household * Monthly Household Income (numbers only, please no symbols) * Approximate Number of Interview Hours (1-99) * Number of Home Visits (under 99) * Months Living in Residence * Have you had treatment for bed bugs in the last three months? * Yes No Where are the children listed below currently sleeping? * Comments/Caregiver Story **CHILD DETAILS** Please enter as much information for each child involved as possible. Scroll to the bottom when complete and click the purple "Submit" button. Child 1: First Name * Child 1: Gender * Male Female Neutral Child 1: Age * Child 1: Race * Asian/Pacific Islander Black or African American Caucasian Hispanic Other Child 1: Bed Type (If a bunk bed is needed for multiple children, please mark bunk for each child.) Single Bed Child 2: First Name Child 2: Gender Male Female Neutral Child 2: Age Child 2: Race Asian/Pacific Islander Black or African American Caucasian Hispanic Other Child 2: Bed Type (If a bunk bed is needed for multiple children, please mark bunk for each child.) Single Bed Child 3: First Name Child 3: Gender Male Female Neutral Child 3: Age Child 3: Race Asian/Pacific Islander Black or African American Caucasian Hispanic Other Child 3: Bed Type (If a bunk bed is needed for multiple children, please mark bunk for each child.) Single Bed Child 4: First Name Child 4: Gender Male Female Neutral Child 4: Age Child 4: Race Asian/Pacific Islander Black or African American Caucasian Hispanic Other Child 4: Bed Type (If a bunk bed is needed for multiple children, please mark bunk for each child.) Single Bed Child 5: First Name Child 5: Gender Male Female Neutral Child 5: Age Child 5: Race Asian/Pacific Islander Black or African American Caucasian Hispanic Other Child 5: Bed Type (If a bunk bed is needed for multiple children, please mark bunk for each child.) Single Bed Child 6: First Name Child 6: Gender Male Female Neutral Child 6: Age Child 6: Race Asian/Pacific Islander Black or African American Caucasian Hispanic Other Child 6: Bed Type (If a bunk bed is needed for multiple children, please mark bunk for each child.) Single Bed Child 7: First Name Child 7: Gender Male Female Neutral Child 7: Age Child 7: Race Asian/Pacific Islander Black or African American Caucasian Hispanic Other Child 7: Bed Type (If a bunk bed is needed for multiple children, please mark bunk for each child.) Single Bed Child 8: First Name Child 8: Gender Male Female Neutral Child 8: Age Child 8: Race Asian/Pacific Islander Black or African American Caucasian Hispanic Other Child 8: Bed Type (If a bunk bed is needed for multiple children, please mark bunk for each child.) Single Bed Thank you!
