• • Date
    
    
• • Check program for referral * Program Descriptions: RINGS - "Real Intimacy aNd Growth Skills" 8-hour program conducted by Marriage Resource Center of Miami Valley for cohabitating, engaged or married couples in a viable relationship. (This is not an appropriate referral if domestic violence is present.) The Tuesday evening class includes childcare and light meal. "Within My Reach" - this is a group program for women that want to learn relationship skills and how to "Decide vs Slide". "On My Shoulders" is a relationship education program from a male perspective and includes training in valuable fatherhood skills. "Smart Steps" is a program for stepfamilies that works with the parents and their children. "Rise Above" is a program provided through Jobs & More that includes the relationship program "Winning in the Workplace". This is a choice for individuals that are unemployed or underemployed that need the "soft skills" needed to obtain a job that leads to greater family stability.
    RINGS (MRCMV program for couples)
    Within My Reach (MRCMV program for women)
    On My Shoulders (ULM/MRCMV program for men)
    Smart Steps (MRCMV program for stepfamilies)
    Rise Above (Jobs&More/MRCMV program)
    Money Smart (Basic Financial Management)
    Case Management to include relationship component. (Select this option if unsure of best option.)
    
• • Referral agency *
    Job & Family Services of Clark County
    Marriage Resource Center
    CitiLookout
    Urban Light Ministries
    Family & Youth Initiatives
    Pregnancy Resource Center
    Other
    
• • If Other, enter agency name
    
    
• • Individual making referral *
    
    
• • Phone
    
    
• • Email (Yours) *
    
    

• • ---

• • Client information

    Basic contact and demographic data
• • Consent for Release of Information Obtained:
    Yes
    No
    This may be faxed to Stacy Phillips at 937.322.7230 or emailed to her at citilookout901@gmail.com.
• • Name
    
    First
    
    Last
• • Partner Name (If applicable)
    
    First
    
    Last
• • Address
    
    Street Address
    
    Other Address (optional)
    
    City
    ...AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundlandNorth CarolinaNorth DakotaNova ScotiaOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Territory
    State/Province
    
    Zip/Postal Code
    
    Region (optional)
    ...United StatesCanadaJapanUnited KingdomAustraliaGermanyFranceSwitzerlandItalyNetherlandsAlbaniaAlgeriaAmerican SamoaAndorraAnguillaAntarticaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBotswanaBouvet IslandBrazilBritish Indian Ocean Terr.Brunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslColombiaComorosCongoCook IslCosta RicaCote D'IvoireCroatiaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEstoniaEthiopiaFaeroe IslandsFalkland Isl. (Malvinas)FijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern Terr.GabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey C.I.GuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslHondurasHong KongHungaryIcelandIndiaIndonesiaIrelandIsle of ManIsraelItalyJamaicaJapanJersey C.I.JordanKazakhstanKenyaKiribatiKorea Republic ofKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLiechtensteinLithuaniaLuxemborgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslMartiniqueMauritaniaMauritiusMexicoMicronesiaMoldova Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherland AntillesNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslNorthern Mariana IslNorwayOmanPakistanPalauPanamaPanama Canal ZonePapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts & NevisSaint LuciaSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSt. Vincent & GrenadinesSurinameSvalbard & Jan Mayen IslSwazilandSwedenSwitzerlandTaiwanTajikistanTanzania United RepublicThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslTuvaluU.A.E.U.S.Minor Outlying IslUgandaUkraineUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican City StateVenezuelaViet NamVirgin Isl (British)Virgin Isl (U.S.)Wallis & Futuna IslandsWestern SaharaYemen Republic ofZaireZambiaZimbabwe
    Country
• • Contact phone *
    
    
• • Contact email An email address is not required but if available, your referral will generate an email to the recipient notifying them that a referral was made on their behalf.
    
    
• • Age of male
    ...Under 2020-2526-3536-5051-65Over 65
    
• • Age of female
    ...Under 2020-2526-3536-5051-65Over 65
    
• • Current relationship status (May check more than 1) *
    Single
    Dating
    Engaged
    Cohabiting
    Married
    Separated
    Divorced
    Stepfamily
    
• • If other, please enter status
    
    
• • Living arrangement (Check all that apply) *
    With partner
    With spouse
    Without partner or spouse
    With parents
    With children
    
• • List gender and ages of children under 18
    
    
• • Highest educational level
    Less than high school
    High school
    Vocational degree
    College degree
    
• • Interpreter need? (Specify language)
    
    
• • Best time to contact client
    
    

• • ---

• • Narrative
• • Programs within your agency that client is/was involved with
    
    
• • Skills needed, concerns, additional pertinent information
    
    

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