Housing Referral Form
Wayne County Human Services
Housing Department
Name of Person Making the Referral
*
First Name
Last Name
Referring Agency/Provider
*
N/A if this is a referral made without ties to an agency.
Preferred Contact Method
*
Phone
Text
Email
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What services does/will this person receive from you?
Consumer Information
(Person you're referring for Housing services)
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Did the consumer call 211?
*
Yes
No
Unsure
Date of Birth
-
Month
-
Day
Year
Date
Address/Last Known Address
*
Street Address
Apt #
City
State / Province
Postal / Zip Code
Monthly Household Income
(If known) - all household members 18 and older.
Why are you referring this person for housing-related assistance?
*
i.e. facing a housing crisis, couch surfing, homeless youth, homeless veteran, homelessness in general, etc.
Prior Living Situation:
*
Couch Surfing
Doubled-up with Friends/Family
Fled Domestic Violence
Homeless (inhabitable place)
Incarcerated (prison, jail)
Rental
Treatment Facility (MH, Recovery)
Transitional Housing
Shelter (Homeless, DV)
Other
Consumer's current living situation?
*
Doubled-up living with family and/or friends (over-crowding)
Couch surfing
Staying in a homeless shelter
Living in a transitional housing unit
Rents an apartment
Owns their own home
Other
What housing services are needed?
*
Case Management
Housing Location Services
Temporary Mortgage Assistance
One-Time Move-in Assistance i.e. security deposit, 1st month rent
Temporary Rental Assistance
Temporary Utility Assistance
Other
Number of Adults in the Household
*
Number of Children (17 or younger) in the Household
*
Barriers to Housing:
*
Drug-related Conviction in the Past 5 years
Violent Criminal Offenses
Registered with Meghan's Law
History of Alcohol Use/Substance Use
Chronic Health Condition
Disabled
No Rental History
Bad/No Credit
History of Eviction(s)
No income
Lack of Transportation
Other
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