Next Steps of

South Carolina (NSSC)

 

Employment and Social Services

Referral Form

The Lazarus Mentor completes this form, giving the original to the Participant to bring to the employment or social services orgnaization to which s/he is being referred, and making a copy of this form and giving it to the Database Management Team Member on duty to transcribe in to the Charity Tracker Plus Database.  The Lazarus Mentor can use the Next Step Program Affiliate telephone number if s/he prefers not to use his/her own phone number.

 

   

TO:

Agency Name

 
 

Address Line 1

 
 

Address Line 2

 
 

Phone Number

 
 

Referral Date

 
     

RE:

Participant Name

 
 

Address Line 1

 
 

Address Line 2

 
 

Phone Number

 
 

Date of Birth

 
     

Reason for Referral 

 

 

 

 

 

Referred by Lazarus Mentor:

 

Phone Numbers:

 

 

Today’s Date

 
           

Additional Lazarus Mentor Notes

 
 

 

 

 

 

 

 

 

 

Please contact Next Step Program Staff Member regarding questions.

(Check One of the Following Next Step Program Affiliates:)

_______Next Steps of Barnabas Ministries (NSBM)

________Next Steps of Johns Island (NSJI)

 

Next Steps of South Carolina is indebted to Samaritan Ministry of Greater Washington (www.samaritanministry.org), Lazarus Ministry of Christ Episcopal Church, Alexandria, VA (www.historicchristchurch.org), and The Cooperative Ministry, Columbia, SC (www.coopmin.org) for allowing us to pattern our Next Step Program after their successful ministries.

(Last modified 4/14/2016)