Mimi's House foundation
Thank you for your interest in referring a participant to Mimi’s House Foundation. Our programs are designed to support young women in developing life skills, emotional resilience, and a clear path toward independence.Please complete this form in full. All information will be kept confidential and used solely to assess eligibility and ensure appropriate program placement.
Referrer Information
Referring Agency / Organization
*
Referring Person
*
Referring Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Email
*
example@example.com
Referral Date
*
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Month
-
Day
Year
Date
Participant Information
Participant Name
*
First Name
Last Name
Participant age
*
Participant Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Email
example@example.com
Parent / Guardian (if minor) and contact info
Program / Division Selection
Adult Division - The Complete 180
Tier 1 - 180 Minutes
Tier 2 - 180 Hours
Tier 3 - 180 Days
Juvenile Division Programs - The Yellow Brick Road
Life After High School - Reality Check workshop
Yellow Brick Road to Independent Living
Yellow Brick Road to Education
Is the Participant on probation
Yes
No
Services Needed
Life Coaching
Mentorship
Accountability
Therapy Referral
Life Skills
Budgeting Planning
Reason for Referral
Reason for Referral
*
Juvenile Probation
Educational Support Needed
Life Skills
Mentorship
Career Planning
At Risk Youth
Aging out of system
Justice Involved / Diversion
At-risk of homelessness
Behavioral Concerns
Other
Internal / Follow-Up Fields
Goals for Participant
Program Assigned (Mimi’s House Use Only)
Tier (Mimi’s House Use Only)
Assigned Mentor (MOM)
Start Date
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Month
-
Day
Year
Date
Case Manager / Probation Officer
Submit Referral
Should be Empty: