Project Belong Referral - Connections Homes

Young Adult Information

Young Adult Name*

First Last

Young Adult Age*

Age explanation, if outside of 18-24.*

Young Adult Birthdate*

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 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?*

Is the young adult currently under a physician or therapist's care?*

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?*

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?*

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)*

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?*

Do we have permission to contact the young adult directly to move forward in the process?*

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.