Life Skills and Independent Living

Referral Instructions

Please complete the referral form below to begin the enrollment process for the Independent Living and Life Skills Program. This program equips youth with the knowledge and practical tools needed to successfully transition into adulthood, with an emphasis on personal responsibility, daily living skills, and long-term stability.

The program is primarily designed for youth ages 13 to 19. Transportation may be available on an as-needed basis. Please note any transportation needs in the additional notes section of the form.

Once the referral form is submitted, our team will review the information and contact the parent or legal guardian to discuss scheduling and payment, unless otherwise indicated in the additional notes section. If you have questions or need assistance, please contact our office for support.

Life Skills and Independent Living

This field is for validation purposes and should be left unchanged.

Student Information

Full Name(Required)
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Your Email Address(Required)
Address(Required)
When is the best time for us to reach you via telephone?

Parent/Guardian Information

Full Name(Required)
Your Email Address(Required)

Case Manager Information (If Applicable)

Full Name
Case Professional Email Address

Service Information

Services Needed(Required)
Transportation Needed?
Preferred Time Block(Required)
Please select one of the available time blocks. While we will do our best to accommodate preferences, placement in the preferred time block is not guaranteed. However, students may be placed on a waitlist for their preferred time slot if it is unavailable. If none of the offered time blocks or days fit your schedule, please let staff know.
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Consent + Agreement

I hereby confirm that the information provided above is true and accurate. By typing my name below, I acknowledge that it serves as my electronic signature.
Consent(Required)
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