DORTHA Assessment
Facts to Thrive is a nonprofit organization that provides training and support in CPR, entrepreneurship, and housing assistance for youth 18-24. This form is used to apply for services needed individual assistance with the Doing Our Responsibility to House Adolescence program.
Email *
Name *
Phone number *
What is your age? *
Ethnicity/Race *
Gender *
Current address (If none list closest street to you)
Below is a questionaire to determine referral assistance potentially needed:
What is your current living situation: *
Are you in school? *
Are you currently receiving any TANF assistance? *
Do you have health care coverage? *
Have you spoken with a mental health counselor in the last *
Are you currently working? *
If working, please provide where?
Have you had a flu shot or covid shot this year?
Clear selection
Type of assistance you are requesting?
Do you have your own personal bank account?
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Is there any additional information you would like to provide? *
By submitting this assessment, I am stating that the questions were answered truthfully. I also understand verification of some information may be requested.
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