Client Referral Form

Thank you for your interest in Restoration Hope's SLS and ILS services. After submitting this form, we will contact you to discuss the referral in further detail. We look forward to meeting you!

Client Referral Form

"*" indicates required fields

Client Information

Client Name *

Preferred Client Language

Client Date of Birth *

Client Address *

Client Phone *

Client E-mail

Other Contact

Relationship to Client

Referring Person

Name of Referring Person (Service Coordinator, Hospital, Other) *

Phone of Referring Person

Email of Referring Person

How did you hear about us? *

Service Details

Region of Service *

Potential Services Start Date

Current Services & Supports: Please include the goals you're hoping this service will address, as well as any other agencies, programs, or supports this client is currently receiving. *

Supporting Documents

If a Regional Center client, please attach the most current IPP, CDER, and Psychological or Social Evaluations (as applicable), as well as any additional relevant documents.

Select Files

Accepted file type: PDF. Max file size: 25MB per file.