SKIL Referral Form

Date*

Date

Contact Name*

First NameLast Name

Contact Phone Number*

Please enter a valid phone number.

Contact Email*

example@example.com

Position*

Student's Name*

First NameLast Name

School*

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Grade*

Sex*

Race*

Provide tribe if Native American

OJA Custody*

YesNo

DHS Custody*

YesNo

Is the student a Senior in High School this year?*

YesNo

If they are a Senior, are they on track to graduate this year?

YesNo

Is the student employed?*

YesNo

If they are employed, do they work part-time or full-time?

Part-timeFull-time

Does the student have a baby/children?*

YesNo

Is the student or significant other currently pregnant?*

YesNo

What are the student's immediate needs?*

Please explain what led the student to become an unaccompanied student. Include all information that is relevant to why the student is living without their parents or legal guardian.*

Transitional Living Program (TINY HOMES)

Tenant Expectations

I will be respectful of staff, self, peers and community residents.
I will remain drug and alcohol free at all times while participating in the program, services will be provided for issues with drugs or alcohol.
I will participate in a life skills group or other services when appropriate.
Participate in job skills training until I secure employment.
I agree to participate in move-in, weekly and pre-move out room inspections with my assigned or other Pivot staff
I will focus on making progress on my goals to become self-sufficient.
I will meet weekly with my assigned Pivot staff member.
I will pay rent per the identified fee schedule.
I will have contact (by text, phone, email, or face to face) with Pivot staff according to the sliding scale
I will go to wellness coaching sessions twice a month.
Visitors allowed only upon prior approval and in line with the visitor policy.
Planned overnight absences from property must be reported to Pivot staff.
Residence is forfeited after 7 days without contact; property will be held for 30 days after which participant forfeits rights to the property.

Are you interested in the Transitional Housing Program (Tiny Homes)?

Yes, I have read the Tenant Expectations and am interested in the Transitional Living Program.No

SKIL Referral Form

After you submit below, a SKIL Advocate will contact you within the next six business days. Three attempts will be made to contact you. If we cannot contact you and you still need assistance, you must repeat this referral process.