Ryan's House for Youth Diversion Referral Form

Ryan's House for Youth Diversion Referral Form
Who is completing this form?*

I am a young adult between the ages of 18-24I have kids living at home between the ages of 13-24I am a referral partner or agency staffNone of the above
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.
Client email*
example@example.com
Clients preferred contact method:*

CallTextEmail
If by call, is it okay to leave a message?

YesNo
What time of the day is best to reach the client?*

Between 9am and noonBetween noon and 4pmBetween 4pm and 8pmNo preference
What best describes the client's current situation or challenge? (Check all that apply)*

At risk of losing housing due to an unexpected expense or financial hardship (e.g., can’t pay rent, high utility bill)I am sleeping outside, in a vehicle, or a place not meant for housingRecently exited foster care, hospital, or detention and do not have stable housingExperiencing conflict or tension at home and may need mediation (for youth or families)Temporarily staying with others (couch surfing or doubled-up)I am in a shelter, transitional housing, or motel paid for by an agency or charity (*must agree to communication with agency or charity already providing services*)I don’t feel safe where I’m livingNone of the above, but I need help finding or keeping stable housing
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.)*

YesNo
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?*

YesNoUnsure
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.
Email*
example@example.com
Best way to reach you:*

CallTextEmail
If by call, is it okay to leave a message?

YesNo
What time of day is best to reach you?*

9am- noonnoon- 4pm4pm- 8pmNo preference
What best describes your current situation or challenge? (Check all that apply)*

At risk of losing my housing due to an unexpected expense or financial hardship (e.g., can’t pay rent, high utility bill)I am sleeping outside, in a vehicle, or a place not meant for housingRecently exited foster care, hospital, or detention and do not have stable housingExperiencing conflict or tension at home and may need mediationTemporarily staying with others (couchsurfing or doubled-up)In a shelter, transitional housing, or motel (paid for by an agency or charity)*must agree to communication with agency or charity already providing services*I don’t feel safe where I’m livingNone of the above, but I need help finding or keeping stable housing
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.)*

YesNoI am not sure
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?*

YesNoI am not sure
Additional notes or concerns
Should be Empty:

Ryan's House for Youth Diversion Referral Form

Partner Referral Form

Self Referral Form