THRIVE HOUSEReferral Form

THRIVE HOUSE

Referral Form

This is transitional living program (TLP) for young single mothers and their children to begin to THRIVE on their own while taking steps toward a safe, stable, and sustainable future.

Criteria:

Open to moms 18 years and older, either with children and/or expecting.
The single moms Thrive House is unable to accommodate housing for partners or co-parents.
Upon acceptance into the program, moms will need to agree to the House Covenant outlining program expectations, rules, and policies, and sign a month-to-month sub-lease agreement.
Note, this is not a subsidized housing program.

Name of person making referral:*

Date of Referral

Phone*

Email*

Organization you are connected to if applicable:

Your position or roll:

How long have you known this mom?

Full Name of mother you are referring:

Mom's Age

What is the mom's current parenting status?

Pregnant

Has 1 child in her custody

Has 2 children in her custody

Child's Age or Due Date

What is this mom's current living situation?

What is this mom's current work/schooling status?

What transportation does she use?

Please explain why you think this mother would be a good fit for Thrive House.

What services or supports do you or your organization currently give to this mom?

Will this mom need to exit your program and why?*

What services might follow this mom if placed in our program?

To your knowledge, has this mom recently experienced suicidal ideation or behavior?

To your knowledge, has this mom recently engaged in self harm?

To your knowledge, has this mom recently abused drugs or alcohol?

What barriers do you believe may hinder the applicant from living independently in the future?

Do you know the applicant to have any behavioral history that could make living in a house with others difficult?

How have you seen the applicant demonstrate motivation and effort to achieve independence?

Is there any other information that might be helpful for us to know in our consideration of this mom?

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