CCC Referral Form Δ Step 1 of 7 14% AS YOU FILL OUT THIS FORM PLEASE MAKE SURE YOU LET THE INDIVIDUAL KNOW: • This form may be shared with other churches or agencies. • There is no guarantee of financial assistance and we realize there will be times we will not be able to stabilize a family/individual’s financial situation. However, we will engage with every family/individual to determine how to best support them in their present circumstance. It may be us providing direct help, or we may determine it is in the best interest of the family/individual to refer them to an outside organization/partner. Our intent is to walk alongside the family/individual until their present circumstance is resolved or until they are more fully integrated into the life of the church. All available resources ultimately come from God, whether they receive assistance from us or from another organization or church. • Provide a picture ID and current copy of the utility bill/invoice for which they are seeking assistance. The bill must be in the individual’s name and address. They need to have a plan to cover any amount we are unable to assist with. Referral InformationName of STAFF / SERVE TEAM LEADER Filling Out Form* First Last I am a Staff Member or Serve Team Member* Staff Member Serve Team Member What is the referred Family/Individual's Relationship to Compassion Christian Church (Select all that apply)* Compassion Member Regular Compassion Attender Regular Lighthouse Guest Serve Team Member Small Group Member Other Specify Other Relationship to Compassion ChristianPersonal Information of IndividualName of Person being Referred (As appears on picture ID)* First Last Date* MM slash DD slash YYYY Email Phone*Phone Type*Please selectHomeCellWorkAre they homeless?* Yes No Address (Utility Bill Address Must Match)* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Select the Compassion Campus the family/individual attends or is nearest to their home* Bluffton Campus Downtown Campus East Campus Effingham Campus Henderson Campus Midway Campus Statesboro Campus Central (Central use only) Here is a link to view on Google maps. Click on the cross nearest you for campus name and address.How long have they lived at their current address?*Marital Status*Please selectMarriedSingleDivorcedSeparatedLiving TogetherWidowed Income Information of Family/Individual Being ReferredPlease list all members in the household providing an income.Name of Person being Referred First Last Age*Please enter a number from 0 to 99.This field is hidden when viewing the formRelationshipPlace of Employment*Individual's Earned Monthly Income (Not including disability or social security)*Individual's Disability or Social Security Benefit*1. Do they have another person in the home?* Yes No Household Member #2* Name Age Relationship Place of Employment Household Member #2 – Monthly Income*Household Member #2 – Disability Benefit*2. Do they have another person in the home?* Yes No Household Member #3* Name Age Relationship Place of Employment Household Member #3 – Monthly Income*Household Member #3 – Disability Benefit*3. Do they have another person in the home?* Yes No Household Member #4* Name Age Relationship Place of Employment Household Member #4 – Monthly Income*Household Member #4 – Disability Benefit*4. Do they have another person in the home?* Yes No Household Member #5* Name Age Relationship Place of Employment Household Member #5 – Monthly Income*Household Member #5 – Disability Benefit*5. Do they have another person in the home?* Yes No Household Member #6* Name Age Relationship Place of Employment Household Member #6 – Monthly Income*Household Member #6 – Disability Benefit*6. Do they have another person in the home?* Yes No Household Member #7* Name Age Relationship Place of Employment Household Member #7 – Monthly Income*Household Member #7 – Disability Benefit*7. Do they have another person in the home?* Yes No Household Member #8* Name Age Relationship Place of Employment Household Member #8 – Monthly Income*Household Member #8 – Disability Benefit*8. Do they have another person in the home?* Yes No Household Member #9* Name Age Relationship Place of Employment Household Member #9 – Monthly Income*Household Member #9 – Disability Benefit*9. Do they have another person in the home?* Yes No Household Member #10* Name Age Relationship Place of Employment Household Member #10 – Monthly Income*Household Member #10 – Disability Benefit*10. Do they have another person in the home?* Yes No Household Member #11* Name Age Relationship Place of Employment Household Member #11 – Monthly Income*Household Member #11 – Disability Benefit*Additional IncomeFood Stamps*Child Support*Any Other Additional Income* Monthly Expenses of Family/IndividualPlease list all estimated monthly expenses. You must answer every question, answer ‘0’ if the question does not apply to them.Rent/Mortgage*Credit Card(s)*Loans*Car Payment(s)*Car Gasoline*Car Insurance*Natural Gas Bill*Electric Bill*Water Bill*Cell Phone(s)*Cable/Internet*Clothing*Daycare Fees*Food/Groceries*All Other Bills* Family/Individual's RequestPlease explain what the family/individual is requesting and what has led them to make this request?*Have they attempted to seek help elsewhere?* Yes No From whom?* Family Friend Government Agency Another Church Compassion Christian Church in the past Have they ever been evicted from a rental property or had a car repossessed?* Yes No Please take a picture of the Individual's Photo ID and bill(s) and upload below. Drop files here or Select files Max. file size: 2 GB. Take a photo of the ID & bill(s), click ‘select files’ or drop them into the box. Individual's Spiritual JourneyHave they accepted Jesus Christ as their personal Lord and Savior?* Yes No No, but they want to know more Have they been baptized by immersion and know that they are forgiven of all sins through His sacrifice?* Yes No No, but they want to know more Do they attend church?* Yes No Which Church do they attend? Compassion – Henderson Campus Compassion – Henderson Campus (Latino Service) Compassion – Bluffton Campus Compassion – Downtown Campus Compassion – East Campus Compassion – Effingham Campus Compassion – Midway Campus Compassion – Statesboro Campus Compassion – Central (Central use only) How often do they attend and when was the last time?*Are they a member of Compassion Christian Church? Yes No Do they serve on a Serve Team at Compassion? Yes No Where do they serve and in what capacityAre they aware of their need? Yes No Have they requested any assistance from them? Yes No What type of assistance?Are they praying about the situation and reading God's word on a daily basis?* Yes No How would they describe their current spiritual life? (Distant from God? Frustrated with God? Angry with God? Confused by God? Seeking God strongly? Drawing closer to God? etc.)*God has given everyone special talents and abilities. What are some of their talents and abilities?*Are they using these talents and abilities? How could they use them better?* STAFF / SERVE TEAM LEADER recommendation* Approve Consider Staff / Serve Team Leader's relationship with family/individual and reason for your recommendation (How do you believe this assistance will help lead the family/individual to a life-changing relationship with Jesus and/or the Church)*Form Completion* This form was completed honestly and to the best of my ability.Individual to Initial HereDecision Team Notes: Document conversations with family/individual with dates and other important contact information throughout referral process. This is information that explains why you made the decision you did.Follow Up Plan: How do you plan to follow up with this family after the initial crisis?
