Community/Emergency Aid Referral
SPECIAL NOTE TO THE REFERRING AGENCY: Please fill this form out to the best of your ability. A representative of the HOME program will contact the client to conduct an interview and obtain a list of needs. A pick up appointment will then be scheduled within one business day in most cases. Please do not send the client to the center with a written referral. If it is an emergency that must be taken care of in a timely manner, please call the office. (810) 667-0055
Community/ Emergency Aid is available to women who are:
-Pregnant or have a child under the age of 3
-Have legal custody of the child
-Living in Lapeer County
-Have a referral from an outside agency
-Can produce a valid photo ID
Emergency/community aid is almost always granted to clients who meet the criteria. After the initial referral, material aid pick up may be available once every six months while the referred child is under the age of 3. Baby clothing is available up to size 4T. Cribs and car seats are not available through this program. Other gently used baby equipment and baby items are subject to availability.  All items must be signed for. No parenting education or mentoring is available in this program.

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Email *
Todays Date *
MM
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DD
/
YYYY
Referring Agency *
Referring Party's Name *
 Daytime Phone Number *
Client's Full Name *
Client's Phone Number *
Marital Status *
Is the client pregnant? *
Child/ children's gender and age *
Living Situation *
Does the client have transportation *
Current Needs- please list specifics *
Is this an emergency need? For instance is the client completely out of formula or diapers? *
Is there anything else we should know before contacting the client?
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