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East Tennessee Collaborative Interest Form

Please fill out the form below to be considered for the East Tennessee Collaborative program.

East Tennessee Collaborative Interest Form

Parent/Guardian's Name:(Required)
MM slash DD slash YYYY
I have custody of a minor child in my home.(Required)
Address(Required)
Knowing your county helps our team match you with a mentor near you.
It is okay to contact me via text message.
I am interested in working with a mentor for these services (check all that apply):
Who would you prefer to serve you through the East Tennessee Collaboration?(Required)
Are you or any of your family members employed by any of the agencies below? (Select "None" if not)(Required)
Who is submitting the referral?(Required)
Please select one, if you are filling out this form for yourself, please select self-referral. After making your selection, please fill out the contact form below with the appropriate information.

East Tennessee Collaborative is a part of a study funded by the Tennessee Department of Human Services which is being conducted to determine how these pilot programs help people improve their economic well-being and become self-sufficient. During the study, all new eligible applicants will be selected by lottery into one of two groups that receives a different mix of program services.

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