Ethos Literacy Referral Form

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Please fill out this form to make a referral to Ethos Literacy.

If you have any questions please call our office at 505-321-9620 or email general@ethosliteracy.org.

We are located at 400 Gold Ave SW Suite 210, Albuquerque NM 87107

Contact Information for person making referral:
Please include your name, title, phone number and email. *

Client Information

Name of person being referred: *

Contact Information for client:
Please include phone number and/or email address. *

Services Requested *

Basic Literacy: reading, writing

ESL: English as a Second Language

Math Literacy

Digital Literacy

Pre-GED

Other:

Required

Demographics of Client

Last grade of school completed: *

Birthdate: *

YYYY

Gender *

Female

Male

Non-binary/Other

Prefer not to say

Ethnicity

Are they employed?

Yes

N/A

Clear selection

Did your client disclose any physical or learning disabilities? (This is for accommodation purposes only.) *

Yes

N/A

If your client has taken an assessment with your organization please include the following information or send documentation to general@ethosliteracy.org.

Date of assessment:

YYYY

Type of assessment:

TABE

CASAS

Please list the assessment form & scale score:

Is there anything else we should know to better serve your client? (Limitations, health conditions, etc.)

Submit

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