Application and Referral Form

Mountain Home provides residential and mental health services to young women and children. Mountain Home’s residential services are offered to women who are between the ages of 16 and 24. Mental health services are offered to mothers of children between the ages of 14 and 29 and any children under the age of 14.

To begin the process for yourself as an applicant or if you are a medical professional referring another, please begin the process using the form below.

Application and Referral

Phone

This field is for validation purposes and should be left unchanged.

Referral Type(Required)

If you are referring someone else, please enter your name, contact information and agency (if applicable)

This referral is primarily for(Required)

Demographic Information

Name of the individual you are referring(Required)

First Last

Age of the individual you are referring

Mountain Home serves young mothers ages 16-24 in residential programs and 16-29 for all supportive services.

Date of birth of the person you are referring

Is the individual currently pregnant?

Yes

No

Is the individual currently parenting?

Yes

No

Is the individual currently homeless?

Yes

No

Where is the individual currently living/sleeping?

Contact Information for the Individual You are Referring

Current Address

City State ZIP Code

Email

Enter Email Confirm Email

Phone(Required)

Is it safe for us to leave a voicemail at this number?

Yes

No

*Disclaimer: It is asked of each individual to complete this application as honestly as possible. The answers provided alone do not affect 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 more information, or to make a referral over the phone, please call our intake coordinator at (406) 541-4663.

Mountain Home Montana is a 501c3 organization providing families a place to live while they access basic needs, mental healthcare, education, employment support, and trauma-informed childcare. Mountain Home gives families the resources, skills, and networks they need to build their own safe, stable, and nurturing homes.

Mountain Home Montana
4720 23rd Avenue
Missoula, MT 59803
(406) 541-4663

Application and Referral Form