Lanawae Housing Center Client Referral Form

Lanawae Housing Center Client Referral Form
Client Information
Client name*

First NameLast Name
New clientPrevious client
Address

House name/no & street

CityState / Province

Postcode
Phone/contact #:*
Gender preference

FemaleMaleNon Binary
DOB*

MonthDayYear
No of dependants
Employment or Benefit Status*
Employment or Benefit Status*

EIA BenefitsAgency Supported BenefitsDisability BenefitsEmployed self/part-time or full timeOther
Disability

YesNo
Details
Referring Agency/Parnter Information
Referring Agency*
Name*

First NameLast Name
Email *
Phone Number*

Area CodePhone Number
Services required*

Emergency HousingSupported Cluster Housing -Stage1Independent Living - Stage 2Family Housing - Stage 3
When is housing required:*

MonthDayYear
Date
Special needs to consider and/or risks identified
If addiction is selected, please fill in the question below. This will help us identify what can be done in an emergency situation or overdose.
Drug of Choice

MethamphetamineDownHeroinFentynlCocaineNarcotic PillsAlcoholOther
If other is selected, please indicate:
Emergency contact*
Contact number*
Fee's and funding information *
A $1000 non refundable intake fee is required to secure placement at Lanawae Housing Center (LHC). This fee is due upon acceptance and before pick up from correctional center and includes 1st month's rent/utilities and food security. Rent of $1000 is due upon the 1st of each month. Please indicate how this will be covered. If EIA is the only funding option, EIA intake appointment must be made by client immediately upon release as this takes several weeks. Failure to fund placement will result in discharge from the LHC program. LHC does not provide funded placement, nor do we seek funding for referred clients.
What is funding plan?

EIAFN BandEmployment
Data protection

Client understands and accepts that their information will be kept securely until it is no longer required to assist them or by law. Permission is granted to Lanawae Housing Center to contact the client by their identified preferred contact method.All information gathered is strictly confidential.
Should be Empty:

Lanawae Housing Center Client Referral Form

Client Information

Referring Agency/Parnter Information