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Client Referral Form

Sponsored by The Senior Source

3910 Harry Hines Blvd., Dallas, TX 75219

Phone: (214) 823-5700

Fax: (214) 826-2441

The Elder Financial Safety Center at The Senior Source is a safe and trusted place for older adults to get expert, professional and unbiased guidance to ensure financial well-being. Our vision is to ensure every older adult lives in a safe community with the financial resources to securely age with dignity.

Our services are wide-ranging and include prevention from too little income and too much debt, as well as frauds and scams through career services, financial coaching, mini loans, benefits assistance, money management, budgeting, insurance counseling, filing a fraud complaint, debt management, and more.

Income and age requirements apply to all program services. Provide as much information as possible to ensure the greatest need is addressed. Complete all applicable sections and a member of the Elder Financial Safety Center team will follow-up.

Date

Step 1: Client Identification

First Name

Middle Name

Last Name

Home Phone

Cell Phone

Mailing Address

Mailing Street

Mailing City

Mailing State

Mailing Zip Code

County

If in Texas and not listed, choose "Other - Texas." If Outside Texas, choose "Out of State."

	Response
Gender:	FemaleMaleOther
Marital Status:
Ethnicity
Hispanic?
Date of Birth (MM/DD/YYYY)

Step 2: Referral Source

Referral Agency

Other Referral Agency

Station Contact First Name

Station Contact Last Name

Station Contact Title

Station Contact Email

Station Contact Phone

Step 3: Reason for Referral

Step 4: Client Status

Other, please list.

	Response
Are they a U.S. Veteran?	YesNo
Is their spouse a U.S. Veteran?	YesNo
Is client homebound?	YesNo
Is client homeless?	YesNo
Is there a current APS Case Filed?	YesNo
Are there others living in the home?	YesNo
If yes, who?

Step 5: Client Financial & Benefits Information

Please enter amounts next to each Income Source (Monthly).
List amounts with no decimals.

		Client ($)	Spouse ($)
Social Security (Monthly)
SSI (Monthly)
Other Monthly Income (indicate source)
Total Monthly Income

Step 6: Client Emergency Contact

Client Emergency Contact

First Name

Last Name

Phone

Relationship

Step 7: Client Support

What other social service agencies are working with the client? Provide agency name, staff person, and staff person’s contact information.

Internal

INTERNAL USE ONLY

DO NOT send confirmation email to referrer.

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Benefits Assistance (i.e. – SNAP (food stamps), Medicare Savings, Extra Help (prescriptions), etc.	Credit Cards/Payday Loans
Debt Management/Bankruptcy	Employment Services
Financial Coaching	Fraud & Exploitation
Insurance Counseling	Mini-Loan Program
Money Management Services	Utility Assistance (TXU & Atmos Energy ONLY)
Other

Isolation/Living Alone	Mental Health Disorder	History of Drug Abuse
History of Alcoholism	Other