The Well CDC Akron -

Career Development Referral Form

Please complete this form to refer your client to our career development program.

First Name *

Last Name *

Email *

Phone *

What is the client’s current housing situation? *

Renting or owning their own housing

Emergency shelter

Transitional housing program

Living with friends or family

Other

Does the client have at least 12 months of sobriety or no substance use concerns? *

Yes

No

Unsure

Name of Person Making Referral *

Email of Person Making the Referral *

Referring Organization *