336.971.4878 info@pivotnow.org

Will you help find the best candidates for Pivot?

 

If so, please identify your top recommendation(s) of low-income, working-age women who are:

  • ready to make a change in life
  • without minor dependents in the home
  • willing to commit and to participate in weekly classes
  • interested in building community with others
  • open to a Biblical foundation and a one-on-one Christian mentor.

Please answer the following questions as you understand each referral’s current situation while honoring your confidentiality agreement.  Required fields are marked with an asterisk (*).

Please be sure to hit SEND (at the bottom of the form) when it’s complete.


1. Referral Source

Your Name *


Your Phone *


Your Email *


Your Organization *




2. Woman You Are Referring

Name *


Address *



Email


Phone


Accepts Texts?
YESNO

Authorized This Referral? *
YESNO

Approximate Age *
18-2425-3435-4445-5455-6465+


3. Why Refer

Why is she right for Pivot? *


Why is Pivot right for her? *


Please describe opportunities or roadblocks she faces that your organization doesn’t address:


Please describe any life change or specific event that makes her ready to make a change: *



4. Your observations


Her motivation:


Her goals or vision for herself:


On a scale of 1 to 10 with 10 being absolute highest, rate this woman's readiness to commit to change in her life: *
12345678910

Interest level in Pivot: *
LowMediumHighVery HighUnknown



5. Her situation


Approximate Annual Income: *
$

Currently Employed? *
NoYes - Part TimeYes - Full time
If 'yes', describe:

Other sources of Income:

Availability for classes/events (check all that apply as you understand her typical schedule)
   Mid-morning/mid-afternoon MTuWThFSa
   Late-afternoon/evenings MTuWThF

Transportation methods (check all that apply)
Independent DriverSpouse/significant otherFamily MemberFriendsPublic TransportationOther:

Would an occasional male instructor be an impediment for her?
YESNOUnknown

Describe or list known obstacles or impediments to her success:


Other programs in which she is participating or has done so in the past:


General summary/history that you can share:



6. Other Comments