Hi! We’re so glad you are interested in the THRIVE! Host Home Network. Here are some initial questions that will help us figure out how best to move forward. Are you already working with a New Horizons case manager/student advocate?* YesNo If yes, what is their name? How long have you been working with them? Are you being referred to the THRIVE! Program by a case manager/youth advocate who is not with New Horizons?* YesNo If yes, what is their name and what organization do they work for? Note: If you have no case manager/advocate and you are self-referring, please contact us by text/phone at (240) 285-9116 or through our Contact Us page. Another note: If you are being referred by a youth worker/case manager, please give them this form once completed so they can send it to us along with their referral form. Thanks!! Now to the more interesting stuff (information about you!) Your Name* Age* Date of Birth* Email* Phone* Social Media Handles* Pronouns Used* Where did you grow up? * How long have you been in Frederick County?* Where are you currently living (e.g. friend’s house, shelter, family, foster care, squatting)? How long have you lived there and how long can you stay?* Do you have a GED or high school diploma? If yes, from where?* YesNo If yes, from where? Are you currently enrolled in school? * YesNo If so, where do you go and what year are you What are some of the things you are working on?* How do you think the THRIVE! Host Home Network will support you? * What are some of the strengths that you would bring into the program?* Are you willing to develop a case plan and work towards your goals together with your case manager/advocate and host volunteers? These goals would include long-term housing plans.* YesNo Are you willing to develop a living contract with the host family? Each host will have their own house expectations and will ask the guest to agree to those rules. Guests may also have their own expectations which can be discussed and added to the contract.* YesNo What kind of host volunteers would you like to live with? What qualities are most important to you?* Do you have any allergies? * In case of an emergency, who would you like us to contact?* Is there anything else you would like us to know?* RELEASE OF INFORMATION Please sign here to authorize SHIP of Frederick County and THRIVE! Host Home Network staff and potential hosts to respectfully share relevant information about you with each other. This will help us find the best match possible for you and also provide you with on-going support. Thank you. Please use your mouse, stylus, or finger to sign your name in this box. Date* GRIEVANCE: If you have a grievance about this program, please speak to your case manager/advocate. They can set up a time to talk with Ed Hinde, Executive Director of SHIP of Frederick to discuss your grievance. Submit
