Refer Clients to CLEARCorps

[contact-form to=’tg@clearcorpsdetroit.org’ subject=’Referral to CLEARCorps Detroit Program’][contact-field label=’Name of Referring Agency’ type=’name’ required=’1’/][contact-field label=’Contact Email’ type=’email’ required=’1’/][contact-field label=’Client%26#039;s Name’ type=’name’/][contact-field label=’Client%26#039;s Address ‘ type=’text’/][contact-field label=’Client%26#039;s Phone Number’ type=’text’/][contact-field label=’I am referring my client to:’ type=’select’ required=’1′ options=’Healthy Homes + Asthma,Lead Safe Homes Program,Refrigerator Replacement’/][contact-field label=’Is there a child under the age of six?’ type=’checkbox’/][contact-field label=’Is there a child with diagnosed asthma?’ type=’checkbox’/][contact-field label=’Their fridge may be built before 2001.’ type=’checkbox’/][contact-field label=’WCHAP ONLY: How many visits have you had with this client? ‘ type=’textarea’/][contact-field label=’Is there anything we should know about this client?’ type=’textarea’/][/contact-form]