Ryan's House for Youth Diversion Referral Form

Ryan's House for Youth Diversion Referral Form
Who is completing this form?
Unfortunately, based on your answers, you are not eligible for this program. Please call 360-682-2748 for information about other available resources.
Partner Referral Form

Please complete this brief form for your client to determine whether they may benefit from diversion support through Ryan’s House for Youth. This takes about 5 minutes.
Today's date:

MonthDayYear
Date
Name of referring partner:

First NameLast Name
Your agency or organization:
Email
example@example.com
Date of initial contact:

MonthDayYear
Date
Name of person seeking assistance:

First NameLast Name
Client phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client email
example@example.com
Clients preferred contact method:
If by call, is it okay to leave a message?
What time of the day is best to reach the client?
What best describes the client's current situation or challenge? (Check all that apply)
Has the client received any financial assistance for housing, bills, or basic needs in the past 12 months?”(Examples: rent help, utility support, hotel stays, emergency gift cards, etc.)
Please briefly describe the type of assistance the client received, when you received it, and who provided it.(For example: ‘Paid rent in March 2024 through Opportunity Council’)
Does the client needing services have a safe and stable place to sleep tonight?
Additional notes or concerns
Self Referral Form

Please complete this brief form to determine whether you may benefit from diversion support through Ryan’s House for Youth. This takes about 5 minutes.
Today's date:

MonthDayYear
Date
Name of person seeking assistance:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Best way to reach you:
If by call, is it okay to leave a message?
What time of day is best to reach you?
What best describes your current situation or challenge? (Check all that apply)
Have you received any financial assistance for housing, bills, or basic needs in the past 12 months?”(Examples: rent help, utility support, hotel stays, emergency gift cards, etc.)
Please briefly describe the type of assistance you received, when you received it, and who provided it. Only share what you remember — even a general idea is helpful(For example: ‘Paid rent in March 2024 through Opportunity Council’)
Do you have a safe and stable place to sleep tonight?
Additional notes or concerns
Should be Empty:

Ryan's House for Youth Diversion Referral Form

Partner Referral Form

Self Referral Form