Closet of Hope Referral /

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Address: 202 S. New Hope Rd. Gastonia NC (located behind Planet Fitness, Hamricks, & Gastonia Grill)

Phone Number: 704-284-3582 Email: info@hope4gaston.com

THIS FORM IS TO BE FILLED OUT BY A SOCIAL WORKER OR OTHER AUTHORIZED, REFERRING INDIVIDUALS.

Referral Date *

YYYY

Referring Organization *

Individual Completing the Form

To best serve our community, referrals can be made twice a year - spring/summer and fall/winter for a two year period. (This policy is subject to change due to the needs of the community.) Employees and families of referring organizations are ineligible to participate.

Name (First & Last) *

Phone Number & Email *

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