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