Referral Form We would like to hear from you. Please send us some info about your applicant by filling out the form below and we will get back with you shortly! Date MM DD YYYY Referring Agency * Contact Name * First Name Last Name Contact Phone Number * (###) ### #### Contact Email * Applicant Name * First Name Last Name Applicant Phone Number * (###) ### #### Applicant Email * In what capacity do you know the applicant? * How long have you known the applicant, and how frequently are you in contact with them? Does the applicant currently have children in their care? If so, how many? Make sure to include if the applicant is pregnant. * Is their current Child Protective Services involvement with your applicant? * Yes No Unsure Are the applicant's kids at risk of being taken out of their care by CPS? If so, due to what? * Is the applicant actively involved in any churches or religious groups? Please list which ones, if you know. * Do you think the applicant would be receptive to coaching and mentoring from a faith based ministry? * Yes No Why do you think they would be receptive to coaching and mentoring? Please describe a specific example, scenario, or interaction you've had with the applicant that proves they will be a receptive of coaching and mentoring. * What is the applicant's current living situation? Do they live in Denton County? * Do you believe the applicant is motivated to get out of their current situation and work towards self sufficiency? And what has the applicant done to lead you to believe this? * What words would you use to best describe this applicant? * Please Rate the Applicant Reliability * Excellent Good Fair Poor Example of Reliability * Consistency * Excellent Good Fair Poor Example of Consistency * Judgement * Excellent Good Fair Poor Example of Judgement * Work Ethic * Excellent Good Fair Poor Example of Work Ethic * Commitment * Excellent Good Fair Poor Example of Commitment * Initiative * Excellent Good Fair Poor Example of Initiative * Caring * Excellent Good Fair Poor Patience * Excellent Good Fair Poor Sense of Humor * Excellent Good Fair Poor Thank you!
