Referral Form
Agencies use this form to refer clients to Tec Centro's services. Please complete one form per individual.
Client Name
*
First Name
Last Name
Client Phone Number
*
Please enter a valid phone number.
Does the client have SMS texting available?
*
Yes
No
Client Email
*
example@example.com
Referring Organization
*
Referring Agent Name
*
First Name
Last Name
Referring Agent Phone
*
Please enter a valid phone number.
Referring Agent Email
*
example@example.com
Our organization exclusively serves individuals who are 18 years old or older. Please confirm your client's age by selecting one of the options below:
Yes, I confirm that my client is at least 18 years old.
No, my client is not 18 years old.
Is the client a SNAP recipient?
*
Yes
No
In what language(s) can the client communicate (select all that apply):
*
English
Spanish
Other
Which services might this client benefit from at Tec Centro? (check all that apply)
*
Employment Services
High School Equivalency (Spanish-only)
English as a Second Language
Workforce Training
Case Management
Harcum College
Basic Computer Class (English/Spanish)
Which level best describes their current English proficiency:
*
Basic (Does not know alphabet, numbers, days of the week)
Intermediate low (Can form short sentences, understands some English)
Intermediate high (Some grammar concepts, able to hold a conversation)
Advanced (higher grammar concepts)
Our High School Equivalency course is taught exclusively in Spanish. Do you wish to proceed?
*
Yes
Does your client need morning or evening classes?
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Morning
Evening
Which school grade level have they completed (either stateside or in their home country):
*
9 or lower
10
11
12
University
Please specify which Workforce Training interests them most:
*
Culinary Arts (English/Spanish)
Dental Assistant (English-only)
Harcum College Associate's Degree (English/Spanish)
Commercial & Industrial HVAC Technology (English-only)
Commercial & Industrial Electromechanical Technology (English-only)
Commercial & Industrial Plumbing Technology (English-only)
Facilities Maintenance Technology (English-only)
Metals Fabrication and Welding
IT Support Specialist (English-only)
Medical Assistant (English-only)
Certified Nurse Assistant (English-only)
Phlebotomy (English-only)
Forklift Training (English/Spanish)
The course you have chosen requires at least a low intermediate level of English proficiency (can form short sentences, understands some English). Is your client at a low intermediate level or above?
*
Yes
The course you have chosen requires at least a high intermediate level of English proficiency (some grammar concepts, able to hold a conversation). Is your client at a high intermediate level or above?
*
Yes
The IT Support Specialist course requires basic knowledge of Windows 10 before beginning the course. Is your client familiar with Windows 10?
*
Yes
Please upload any documents necessary for your client's file with Tec Centro
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