Closer To Home
Referral
Referring Agency/Program
Person Completing This Form and Contact
*
Please Provide the Following Information Regarding Individual(s) Needing Housing
Name
*
First Name
Last Name
Date of Birth
*
Phone Number
Please enter a valid phone number.
Current Location
*
Spouse/ Children Name and Ages
Circumstances Which Led to Homelessness
Willing To Move To Another County (where housing/beds may be available)?
Yes
No
Please send any supporting documents FL2, medical history ect to Email: Closex2xHome@gmail.com or Fax: 980-248-2610
Do Individual(s) have any income. Please list income source
*
Do Individual(s) receive any benefits /services? If Yes, who and what services?
*
Is rent assistance funds available? If yes, how much and what program?
Room/bed fill up fast. Rates are income based. Individual(s) WILL need some income to the accepted. We do NOT provide single family homes for families in need . We have temporary family rooms. We will contact the individual within 72 hrs assess their needs
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