Clients should only be referred to Grand Valley Connects if the client is aware that a referral is being made on their behalf and they have expressed interest in receiving assistance from Grand Valley Connects.

Client's First Name*

Client's Last Name*

Clients will only be contacted if the organization's name and good contact information is entered below.

Organization doing referral*

Organization's Contact Information* (name and phone)

Client Permission*

Client requested help with*

Please list only the needs the client themselves has requested assistance with, not those identified or assumed by the referring party.

Client Contact Method*

Client's Phone, Text # or Email'*

Security Code* (Enter

)

Admin Login

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