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Young Adult Referral Form
Please choose the state the Young Adult lives in.
*
This will help ensure your form submission is routed to the correct office.
Georgia
Texas
Other
Young Adult Information
Young Adult Name
*
First
Last
Young Adult Age
*
Under 18
18
19
20
21
22
23
24
Over 24
Age explanation, if outside of 18-24.
*
Young Adult Birthdate
*
Date Format: MM slash DD slash YYYY
Young Adult Email
*
Enter Email
Confirm Email
Young Adult Phone Number
*
Young Adult Current Residential Address
*
Street Address
Address Line 2
City
State
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Your Information
(if you are "self-referring" just input "SELF" into the lines below.)
Your Name
*
First
Last
Your Phone Number
Your Email Address
*
Your Organization
*
Why is this young adult being recommended to Connections Homes for connection?
*
Family History
This section helps us to gather basic information about a young adult's family background.
Describe young adult's relationship with their biological or adopted parents...
*
Describe young adult's history in foster care, or other institutional care (i.e. homeless shelter or residential program)...
*
Medical & Mental Health History
This section helps us to gather basic medical and mental health history.
Describe any medical conditions or treatments that the young adult is currently receiving, or has received...
*
Describe any mental health diagnoses that the young adult is navigating including depression, suicidal thoughts/behaviors, bi-polar disorder, etc.
*
Does the young adult have any current prescriptions?
*
Yes
No
Is the young adult currently under a physician or therapist's care?
*
Yes
No
Does the young adult have a history of substance abuse or alcoholism?
*
Yes, current and excessive
Yes, current and occasional
Yes, in treatment
Yes, successfully overcome
Yes, only occasionally, in the past
Yes, social drinker, but no drugs
Yes, social drug use (this includes the use of pot)
No, has never used drugs or alcohol
Does the young adult have a history of:
*
Emotional Abuse
Physical Abuse
Sexual Abuse
Sexual Exploitation
Verbal Abuse
Domestic Violence in Family
Neglect
Major trauma (i.e. adoption, divorce, loss of close loved one to death...)
None that are known
Educational History
This section is used to gather basic educational information for the young adult
Level of School Completed:
*
GED
High School Diploma
Needs 12th Grade
Needs 11th Grade and Above
Needs 9th Grade & Above
Some College
College Graduate
Working on GED
Does the young adult have a desire to finish school or move onto a college education?
*
Yes
No
Describe any educational information that Connections Homes should be aware of:
*
Connection Readiness
This section is designed to help us understand if the young person is ready for the responsibility and opportunity of a lifelong, stable connection in their life. Connections Homes is not a shelter, temporary housing program or traditional transitional living program. We focus on creating lifelong, stable connections between a young adult and an individual/family who will walk alongside them as they transition into Connected Independent Adulthood—living a fully-functional adult life while maintaining a healthy and accountable connection to someone else. As such, a key foundation of our program is the "connection readiness" of the young adult.
Has the young adult expressed an interest in being a part of a stable, lifelong family?
*
Yes
No
Unsure
Is the young adult self-motivated with a desire to do their part inside of a committed, stable relationship? (i.e. communication, truthfulness, and healthy accountability)
*
Yes
No
Unsure
In your own words, describe the young adult's connection readiness and any hurdles that you feel might need to be overcome...
*
Does the young adult know that this referral is being made on their behalf?
*
Yes
No
Do we have permission to contact the young adult directly to move forward in the process?
*
Yes
No
Consent
*
I understand.
All information provided is confidential. By submitting this form, you are providing Connections Homes with sensitive information for the purposes of locating a stable, permanent family connection for the young adult referenced. Information obtained will only be shared with Connections Homes staff and providers necessary in the location of a suitable connection. Suitable connections will not receive information on the young adult without the permission of the young adult and/or the referring facility.
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The Problem
Get Involved
Refer A Young Adult
Become A Mentoring Family
Be An Agent for Change
Help Create Lifelong Connections
GA Fostering Success Act
Events
Programs
Don’t Go Alone
Career Connection Center
Blog
About Us
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Board of Directors
Our Team
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Press and Media
Careers
Donate
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