Mountain Home Montana: Application and Referral Form

* Disclaimer: It is asked of each individual to complete this application as honestly as possible. The answers provided alone do not effect whether the referred applicant will be able to participate in Mountain Home Montana programs. Eligibility will be determined during an intake interview which will be scheduled after this application is submitted. For mroe information, or to make a referral over the phone, please call our intake coordinator at (406) 210-3243.

 

Demographic Information
Please include first and last name.
Mountain Home serves young mothers ages 16-24 in residential programs and 16-29 for all supportive services.
If so, please list provider
Contact Information for the Individual You are Referring