NBB Referral Form

Referral Form
HEAD OF HOUSEHOLD INFORMATION
Name*

First NameLast Name
Phone Number
Email
Address

Street Address

Street Address Line 2

CityState

Zip
Social Security Number*
Date of Birth*

MonthDayYear
Date
Gender

FemaleMaleTrans Female (MTF or Male to Female)Trans Male (FTM or Female to Male)Non-BinaryDon't KnowPrefer Not to Answer
Pronouns

She/Her/HersHe/Him/HisThey/Them/Theirs
Race

Native American, Alaska Native, or IndigenousAsian or Asian AmericanBlack, African American, or AfricanNative Hawaiian or Pacific IslanderWhiteDon't KnowPrefer Not to Answer
Ethnicity

Non-Hispanic/Non-Latin(a)(o)(x)Hispanic/Latin(a)(o)(x)Don't KnowPrefer Not to Answer
Interpreter Needed:

YesNo
Primary Language:
Does Head of Household have a Serious Mental Illness?

YesNo
If yes, please list diagnoses
If yes, please list mental healthcare provider (therapist/psychiatrist)
Does Head of Household have a guardian?

YesNo
If yes, please list guardian's name and contact information
Does individual have a payee?

YesNo
If yes, please list payee name and contact information.
Does Head of Household have medical insurance?

YesNo
Services that you are requesting (please check all that apply):

Case ManagementNew Beginnings Housing ONLYSupported Living (24 hour supervision in shared home)
Who Referred You to New Beginnings*
Medical Providers please fax admit/discharge, evaluation/assessment, medication list, and E/M notes to 859-245-2443
Referral Contact Information*
PRIORITY INFORMATION

You may qualify for a preference for housing assistance if any of the following circumstances can be verified for your family. Please check any that currently apply to you.
Are you currently residing in a hospital, personal care home, or treatment facility?

YesNo
If yes, where?
Are you living in an emergency shelter?

YesNo
If yes, what shelter?
Are you residing in a place not meant for human habitation?

YesNo
If yes, where did you sleep last night?
Are you residing in a transitional housing program for homeless persons?

YesNo
If yes, what program?
Are you facing imminent risk of losing your primary nighttime residence?

YesNo
If yes, why?
ADDITIONAL INFORMATION:
New Beginnings staff will contact you to schedule an appointment to discuss your referral. I understand that this referral provides only preliminary information, and that no final determination of eligibility will be made until the full process is completed.

I certify that the information provided on this pre-application is true and accurate. I authorize New Beginnings to verify this information. I understand that false information will result in my application being cancelled or denied.

I understand it is my responsibility to inform New Beginnings, Bluegrass of any changes to my address or telephone number and understand my application may be cancelled if I fail to do so.
Signature

Clear
Date

MonthDayYear
Date
It is the policy of New Beginnings, Bluegrass to promote nondiscrimination and ensure fair and equal housing opportunities for all. We are fully committed to promoting and engaging the participation of all people regardless of race, skin color, religion, sex, age, national or ethnic origin, familial status, disability, sexual orientation, or gender identity. Persons with language barriers may request or arrange interpretation alternatives or services.
Should be Empty:

Referral Form

HEAD OF HOUSEHOLD INFORMATION

PRIORITY INFORMATION