Neighbor Referral

Love INC Neighbor Referral Form

Love INC accepts referrals from churches, caseworkers, or other non-family members who know the person’s situation. By submitting this form, you are indicating that you are qualified to refer a client/neighbor to Love INC of Lake County.

Upon receipt of this form, our volunteers will reach out to learn more about this person’s/family’s situation to understand how our churches might be able to support in their current circumstances.

Neighbor Contact Information

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Birth Date

Please choose ONE of the following situations:(Required)

WE ARE VERIFYING that this person's needs are genuine.

OUR CHURCH/AGENCY IS WILLING TO HELP after this person completes the Love INC verification process.

We are sending this information FOR TRACKING PURPOSES ONLY.

This neighbor speaks Spanish only / English is limited(Required)

Yes

This person/family is in need of help with:(Required)

Please briefly summarize your knowledge of this person's/family's situation:(Required)

Our church/agency has been able to help them with:(Required)

We have also referred this person to the following resources/agencies:

Referring Agency/Church Contact Information

Name of Contact Person(Required)

First Last

Your Church/Agency Name(Required)

Name of Agency Program (as applicable)

Your Phone(Required)

Your Email(Required)

Release of Information Authorization Form

Please complete the form below or download and sign this form and email to verify@loveinclakecounty.org.

I would like to complete the Release of Information Authorization form by(Required)

Completing online

Uploading my own

Date(Required)

Client's Signature(Required)

Witness Referring Agency/Church Signature(Required)

Name of Witness(Required)

First Last

Upload File(Required)

If you have a file you want to share or use your own ROI, please upload below.

Max. file size: 128 MB.

Next Steps

Once submitted, please have person in need contact the Love INC Help Center at 847.782.8630 and choose option 1 to confirm receipt of information. Love INC cannot accommodate walk-ins at our office — we are a volunteer call center only.

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Neighbor Referral

Love INC Neighbor Referral Form

Neighbor Contact Information

Referring Agency/Church Contact Information

Release of Information Authorization Form

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