SGTLC Referral Form
Referral and intake form for the South Georgia Transitional Living Center (SGTLC) for young adults ages 18–24 transitioning to independence.
Section 1 – Referral Type
Referral Type
*
Please Select
DFCS / ILP Referral
Agency / Community Partner Referral
Self-Referral
Section 2 – Referring Party Information
Agency / Organization Name
*
Contact Person
*
Title / Role
Referring Party Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Party Email
*
example@example.com
Referring Party Organization Type
DFCS / ILP
Homeless Shelter
Community-Based Organization
School / College
Probation / Court
Other
Section 3 – Applicant Information
Applicant Full Legal Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Applicant Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Applicant Email
example@example.com
Section 4 – Current Housing Status
Current Housing Status
*
Literally homeless
Staying in shelter
Couch-surfing
At risk of losing housing
Exiting foster care
Exiting juvenile justice
Other
Section 5 – Eligibility Screening
Eligibility Criteria Met
*
Age 18–24
Aged out of foster care
Experiencing homelessness/housing instability
Willing to participate
Able to live in shared setting
Other
Section 6 – Education & Employment
Current Education Status
Not enrolled
Enrolled in high school/GED
Enrolled in college/vocational
Completed high school/GED
Other
Highest Grade/Level Completed
Current Employment Status
Unemployed
Employed part-time
Employed full-time
In job training
Other
Employer/Program Name
Section 7 – Reason for Referral
Reason for Referral / Why this program is a good fit
*
Section 8 – Current Needs & Services Requested
Current Needs / Services Requested
Safe housing
Life skills
Education support
Employment/job readiness
Mental health
Substance use
Financial literacy
Transportation
Legal support
Other
Section 9 – Safety / Special Considerations
Safety Concerns / Special Considerations
Section 10 – Applicant Consent
Applicant Signature
*
Applicant Signature Date
*
-
Month
-
Day
Year
Date
Section 11 – Referring Party Authorization
Referring Party Signature
*
Referring Party Signature Date
*
-
Month
-
Day
Year
Date
Section 12 – Internal Use Only
Referral Received Date
-
Month
-
Day
Year
Date
Reviewed By
Referral Status
Pending
Accepted
Waitlisted
Declined
Internal Notes
Submit Referral
Submit Referral
Should be Empty: