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
Preferred Language
In what language(s) can the client communicate:
*
English
Spanish
Other
Referring Organization
*
Referring Agent Name
*
First Name
Last Name
Referring Agent Phone
*
Please enter a valid phone number.
Referring Agent Email
*
example@example.com
Is the client a SNAP recipient?
*
Yes
No
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)
Our High School Equivalency course is taught exclusively in Spanish. Do you wish to proceed?
*
Yes
Does your client need morning or evening classes?
*
Morning
Evening
Does your client need afternoon or evening classes?
Morning
Evening
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)
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(s) interest them (check all that apply):
Culinary Arts (English/Spanish)
Dental Assistant (English-only)
Harcum College Degree (English-only)
Commercial & Industrial HVAC Technology (English-only)
Commercial & Industrial Electrical Technology (English-only)
Commercial & Industrial Plumbing Technology (English-only)
Facilities Maintenance Technology (English-only)
Computer Software Information Systems (English-only)
Certified Nurse Assistant (English-only)
Medical Assistant (English-only)
Healthcare Office Assistant (English-only)
Phlebotomy (English-only)
Forklift Training (English/Spanish)
Please specify which Workforce Training interests them most:
Culinary Arts (English/Spanish)
Dental Assistant (English-only)
Harcum College Associate's Degree (English-only)
Commercial & Industrial HVAC Technology (English-only)
Commercial & Industrial Electrical Technology (English-only)
Commercial & Industrial Plumbing Technology (English-only)
Facilities Maintenance Technology (English-only)
IT Support Specialist (English-only)
Medical Assistant (English-only)
Certified Nurse Assistant (English-only)
Healthcare Office Assistant (English-only)
Phlebotomy (English-only)
Forklift Training (English/Spanish)
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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