Referral Application

Thank you for taking the time to complete this form. Our program provides a safe, supportive environment for young adults transitioning to independence. Your responses are kept confidential and used solely to help us understand how best to support you.

If a question ever feels uncomfortable, put N/A and we'll come back to it together later.

After you submit, a Solid Rock staff member will contact you within 48 hours to set up an in-person meeting and discuss the program and entry process.

Basic Information

First name *

Last name *

Date of birth

City of birth

State of birth

Contact Information

Email *

Phone number

Current address (if applicable) or current place of shelter

Identification

Please select the forms of identification you currently have

If you don't have any of these yet, that's okay — helping you get them is Step 1 of the program.

Status at Entry

Which of these have you already completed? Select all that apply.

Foster Care Background

Have you been in foster care at any point in your life?

Current DCFS status

If you aged out of foster care, when?

State you were in foster care

County you were in foster care

Family Information

Do you have children?

If so, how many?

What are their age(s)?

Are you currently pregnant or expecting a child?

Current relationship status

Mother's first and last name

Mother's contact information (if known)

Father's first and last name

Father's contact information (if known)

Emergency contact name

Emergency contact phone

Program Referral Information

How did you hear about our program?

If referred by a caseworker, please provide their information.

Caseworker full name

Caseworker phone number

Caseworker email

Demographic Information

For data and grant reporting purposes only.

Gender

Which race / ethnicity do you identify with?

Age group

Education & Employment

Highest level of education completed

Did you graduate high school?

If yes, what high school did you graduate from? (if no, put N/A)

Current employment status

If employed, where are you currently working?

Do you currently have banking established (checking and savings)?

Health Care

Do you currently have a primary care physician?

Primary doctor's name

Have you been diagnosed with a mental health condition for which you are currently prescribed medication?

If yes, please list the condition(s) and medication(s)

If yes, please list current healthcare provider

Are you currently enrolled in mental health support classes?

If yes, where and how often?

Are you currently enrolled in life skills classes?

Legal Background

Please note that this does not eliminate you from the program.

Have you been convicted of a crime?

Do you have any ongoing criminal charges filed against you?

If yes, what is the charge(s)?

Anything Else

Anything else you'd like the Solid Rock team to know

Consent and Agreement

By submitting this referral form, I confirm that the information provided is accurate and authorize Solid Rock Youth Transitional Services to use this information for the purpose of providing support services and assistance during my time in this program.

Signature (type your full name) *

Date