TPW Online Referral Network Partner Referral Form This is form is used for partners to refer individuals age 16 - 24 that have barriers to achieving career success and are in need of support, skills, mentoring, and/or guidance once they are out of high school. OK Question Title * 1. Tell us about the person you wish to refer to us. Name (first name is sufficient for referral purposes): Parish where they reside: Email Address, if known: Phone Number, if known: OK Question Title * 2. School Information: Graduated from High School? Will be graduating this school year? Dropped out or about to drop out of High School? OK Question Title * 3. Do they possess a barrier that may make them eligible for our Youth services? A graduate who is low income and lacking basic skills or an English language learner, OR one or more of the following barriers: Disability/IEP or 504 Plan in High School Involvement with the foster care system Homeless/runaway Recent Out-of-home placement Prior Arrest Pregnant or parenting Yes No OK Question Title * 4. Your Information Name Name of referring Agency or School Email Address Phone Number OK Question Title * 5. You can also reach our Youth Program Team: Denise Davillier, Director of Youth Services at ddavillier@triparishworks.net Stacie Chitwood, Youth Coordinator - St. Tammany at schitwood@triparishworks.net George-Anna Watts, Youth Coordinator - St. Bernard/Plaquemines at gwatts@triparishworks.net OK DONE
