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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
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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 can be made twice a year - spring/summer and fall/winter. (Employees and families of referring organizations are ineligible to participate.
Name (First & Last)
*
Your answer
Phone Number & Email
*
Your answer
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