Moab House Referral Form

Moab House Referral Form

This form will take approximately 10 minutes to complete. Please provide as much detail as you are able.
READ CAREFULLY

To be eligible for Moab House, the Young Adult (YA) must be emancipated from foster care, must be 18-20 years old, may not be a convicted sexual offender, must be WILLING to learn the skills necessary for successful independence, and must be law-abiding.

Moab House's mission is to provide safe, loving, and productive transitional housing to former foster youth between the ages of 18-21 who have emanipated from the foster care system.

Moab House is a co-ed dorm-like building geared toward teaching independence and respect for our neighbors. Moab House does not provide emergency placement services. At the end of this form you will be asked for a few meeting dates/times that work best for your schedules. This is so that we can meet your YA and interview them. You and your YA must be able to meet at Moab House, located at 1960 E. Countyline Rd Building 8, Mineral Ridge, OH 44440. Virtual meetings will not be considered. After the initial meeting, we will contact you within 3 business days to give our decision. If your YA changes their mind at any time, we kindly just ask that you let us know. We understand!

We look forward to meeting your YA!
Section 1. Referrer Info
Urgency*
Please describe your role:

Bridges LiaisonCounty CaseworkerCounty Independent Living WorkerFoster ParentOther
Your Name*

First NameLast Name
Your County/Company*
Your Email*
example@example.com
Your Phone Number*
Please enter a valid phone number.

Section 2. Young Adult Info
YA Name*

First NameLast Name
County Emancipating From*
YA Current City of Residence*
YA Phone Number
Please enter a valid phone number.
YA Email
example@example.com
Current Housing*

Foster HomeGroup HomeResidentialOther
Housing Facility Name (if applicable)
YA Birthdate*

MonthDayYear
Date
Is the YA 18?*

YesNo
YA Emancipation Date*

MonthDayYear
YA must have emancipated from foster care to be eligible for Moab House. Future emancipation dates are acceptable.
YA Gender At Birth*
YA Gender Identification*
How long does the YA need to live at Moab House?

Section 3. School
Is the YA graduated?*

YesNo, the YA is a SeniorNo, the YA is a JuniorOther
School currently attending
Graduation Year
Post-graduation Plans*

CollegeTradeschoolNot Interested in SchoolUnsureOther
Comments regarding school

Section 4. Work
Does YA work?*

YesNo
If NO, please explain why.
Does YA plan to keep their job after emancipation?*

YesNoOther
Employer
City employment is located in
How long have they worked at their current job?
Notes regarding work
How long have they worked at their current job?

MonthDayYear
Date

Section 6. Bridges Info
Is the YA currently enrolled in Bridges?*

YesNo
If No, why not?
If Yes, Bridges Company and Liaison Name
Bridges Liaison Phone Number (if applicable)
Please enter a valid phone number.
Reason for Referral*

Living Independently, but unsuccessfullyWill be 18 within 1 monthWill be 18 within 1-3 monthsWill be 18 within 3-6 monthsWill be 18 within 6-9 monthsWill be 18 within 9-12 monthsOther
Please explain "other"

Section 8. Initial Meeting
Please provide preferred dates and times for an initial meeting and tour of Moab House.
Preferred Date/Time #1 Please indicate a preferred date and time for a Moab House Tour. Tours typically take 1 hour.*

MonthDayYear
Date
Hour MinutesAM/PM Option
Preferred Date/Time #2 Please indicate a preferred date and time for a Moab House Tour. Tours typically take 1 hour.*

MonthDayYear
Date
Hour MinutesAM/PM Option
Preferred Date/Time #3 Please indicate a preferred date and time for a Moab House Tour. Tours typically take 1 hour.*

MonthDayYear
Date
Hour MinutesAM/PM Option
Preferred Moab House Move-In Date

MonthDayYear
Date
Please provide any additional notes/comments about the FY
At the initial meeting we will review your form and ask any additional questions that we have. This is the perfect time for you and your young adult to ask questions! After that, we will take you on a tour of our building so that your young adult can see where they could be living.

As a Christian organization, the Moab House team will take 3 business days to pray about the young adult and decide if they would be a good fit for our house. After those three days, we will reach out with our decision by email.

Upon acceptance, we will have the young adult come to to Moab House on Signing Day to sign all forms (if they are 18), or we will wait until their 18th birthday to have them sign. We will set their move-in date and issue their keys on that day.

We could not be more excited for your young adult! :)
Should be Empty:

Moab House Referral Form

Section 1. Referrer Info

Section 2. Young Adult Info

Section 3. School

Section 4. Work

Section 5. Health

Section 6. Bridges Info

Section 7. Transitional Housing Questionnaire

Section 8. Initial Meeting

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