This form is to be completed by referral agency ONLY:

In order to ensure that your referrals receive prompt consideration, please ensure that the Northland Clothing Center (formerly Clay County Clothes Closet) digital referral is completed in full before you submit. We will not be able to accept or schedule referrals for clients with incomplete or omitted information.
Following your form submission, an NCC appointment scheduler will email you a date and time for your client’s clothes fitting appointment. This correspondence will be directed back to the Referring Agency/Agent contact on the referral.

AGENCY REFERRAL FORM

If you have any questions or comments regarding our online submission process, please contact us before submitting your referral. We are happy to clarify any questions you might have about this process.
Some older browsers may not be compatible with this web form. Please use the provided PDF form instead.

Download copy of our Referral Form (PDF) here for submission via fax or email.

Referral Date*
MM slash DD slash YYYY
Client Name*
Client's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Client's Phone: Home

Please enter "N/A" if none available
Client's Phone: Cell

Please enter "N/A" if none available
Client's Email
Has Client received clothing in the last (12) months?*
- Yes
- No
When did this client Last receive clothing?*

Your prior response indicates that this client has received clothing from us in the last 12 months.
Additional Remarks
Please List All Individuals In Household To Receive Clothing*
Name Age Gender (M/F) Ethnicity

Use the +/- buttons at the end of the row to add or subtract as many lines as needed for each member of the household being served
Referring Agency*
Referring Agent's Name*
Referring Agent's Email*
Enter Email Confirm Email

Name	Age	Gender (M/F)	Ethnicity

Please read Referral Guidelines before submitting:

This form is to be completed by referral agency ONLY:

AGENCY REFERRAL FORM