Closet of Hope Referral
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 *
MM
/
DD
/
YYYY
Referring Organization *
Your answer
Individual Completing the Form
To best serve our community, referrals cannot be made more often than once quarterly.
(Employees and families of referring organizations are ineligible to participate.)
Name (First & Last) *
Your answer
Phone Number & Email *
Your answer
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