LIFT Internal Referral

BLUEPRINTS STAFF INFORMATION

Staff Name:(Required)

What is your name?

In which Program Service Area do you work?(Required)

FAMILY INFORMATION

What is the participant's name?(Required)

In which Blueprints' program(s) does the family participate?(Required)

How many family members are in the household?(Required)

What is the family's source of income(s)? (Check all that apply.)(Required)

Part-time employment

Full-time employment

County Assistance (SNAP, TANF, etc.)

Social Security

Other

LIFT INFORMATION

What is the estimated amount needed?(Required)

What type of obstacle is the family facing?(Required)

Please be specific:(Required)

(Please include any information regarding the needs of the family such as tire size, appliance type/size, measurements, etc.)

What is the year, make, and model of the vehicle?

Is the vehicle registered and insured?

Yes

What is the mileage of the vehicle?

What else can you tell us about this family's situation?(Required)

Please attach any documentation to accompany this LIFT.(Required)

Documentation needs: estimates for repair services or tires, online items such as bedding, etc. Please ensure the document is legible and easy to read. **Please note - If your document shows tax fees, you may be asked to contact your family for a new estimate with the tax removed.

Drop files here or

Accepted file types: pdf, jpeg, png, Max. file size: 50 MB, Max. files: 5.

Would you like administrative staff to contact you regarding this LIFT?

Have more information you'd like to speak to us about regarding the family situation? Let us know, we'll chat!

Yes