Runaway and Homeless Youth Services (RHY) Referral Form

  • Runaway and Homeless Youth Services (RHY) Referral Form

  • Service Information

    Please read service information below for program information and eligibility

  • United Action for Youth (UAY) Runaway and Homeless Youth (RHY) Programs provide services and support to youth experiencing homelessness.

    Program Services include:

    • Street Outreach Program (SOP) 
    • Transitional Living Program (TLP)
    • Maternity Group Home (MGH)
    • Youth Prevention and Response Program(YHDP) 

    Program Eligibility:

    • Unhoused/Homeless Youth ages 12-24
      • SOP - ages 12-21
      • TLP - ages 16-22
      • MGH- ages 16-22
      • YHDP - ages 16- 24
    • Unhoused/Homelessness is defined as the condition of lacking stable, safe and functional living space/housing.  This generally includes living on the streets, moving between temporary accomodations such as family or friends, or living in sutuations with no security of tenure

    Program Services Areas: service area includes the following Counties within Iowa:

    • Cedar (MGH, SOP, TLP and YHDP)
    • Johnson (MGH, SOP, TLP and YHDP)
    • Washington (MGH, SOP, TLP and YHDP)
    • Iowa (TLP)
    • Muscatine (MGH and TLP)

    Program Services include:

    • Outreach services
    • Supportive Residential Services
    • Aftercare services
    • Coordinated case management and advocacy 
    • short-term housing and financial assistance(YHDP Only)

     

    To Complete Referral Form Click the next button below to continue

     

  • Please select program you are referring to:*
  • I am filling out this referral form for:

  • Referring Person's Information

    Please complete your information below
  • Format: (000) 000-0000.
  • Your Please choose one of the following for the phone number listed above*
  • In the event we need to contact you, what are your preferred ways to be contacted? (Please select all that apply)*
  • What is your relationship to the youth/your role in the community?*

  • Referral Information

    Please complete the information below.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Please choose one of the following for the phone number listed above
  • Preferred ways of contact? (Please select all that apply)

  • General Information

    Please complete the information below
  • Describe current living situation?*

  • Dependent Care Situation

  • Please select the appropriate choice below*

  • Dependent Care Information

    Please complete information below
  • Please select approximate due date of pregnancy
     - -

  • Additional Information

  •  

  • RHY Program Sort Criteria

  • Date passed or contact
     - -
  • Referral passed to:

  • Sort Criteria

  • Withdrawal Explanation

  • Thank you for taking the time to complete RHY Program Referral Form

    Please click submit button below to submit the referral.  If you need immediate

    assistance please contact the UAY Eastdale office at 319-338-7518 or

    SOP@unitedactionforyouth.org.

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