P-I-E Transitional Housing Program
Theory Approach Inc Referral Form: Housing Program Referral Requirements Before completing this referral form, please ensure the following conditions are met: The family must have custody of their child or children at the time of this referral. The family must identify as homeless, which includes living on the street, in a car, shelter, or hotel. Families in overcrowded conditions, such as a large family in a one-bedroom unit (either on their own or with a family member), also qualify. If the parent is unemployed, they must be open and willing to secure W-2 employment within 90 days. This program is available by referral only and must be submitted by CPS, FBSS, or other social service agencies.
Information about Professional person Completing Referral
Professional Name:
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Professional Title:
*
Example: Social worker, case worker, LPC
Agency or Organization making the referral:
*
Example: FBSS, CPS, Texas Children's Hospital or School.
Family or Individual Information
Family Insurance Provider:
*
Community Health Choice
Texas Children Health Plan
Molina Healthcare
Superior Health (Star)
Other (Pro-Bono)
Parent or Individual Name:
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/ Individual Date of Birth
*
-
Month
-
Day
Year
Insurance #:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If individual do not have address:
Homeless
Hotel
Homeless Shelter
Living with Family
CASA
Homeless Shelter or Hotel location:
Child Name 1:
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Insurance #:
Child Name 2:
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Insurance #:
Child Name 3:
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Insurance #:
Does the client or family identify as homeless? (The definition of those who are experiencing homelessness includes: An individual or family who lacks a fixed, regular, and adequate nighttime residence, such as those living in emergency shelters, transitional housing, or places not meant for habitation). If Yes please select.
Hotel/Motel
Living with family/friends
Shelter
Car
Does anyone in the family have behavior/mental health concerns or a known mental health diagnoses?
*
Yes, concerns
Yes, Known Diagnoses
No
Maybe
How many individuals are in the family?
*
Do the client have legal custody of their children?
*
Yes
No
Services your client/family needs:
Domestic Violence Coaching
Adolescent behavioral Services
Parenting Classes
Case Management
FBSS/CPS Services
Mental Health Services
Foster care Youth to Young Transition
Teen Pregnancy
Substance Abuse services (LCDC)
Which population does your client meet:
Domestic Violence Survivor
Sex Trafficking Survivor
Individual or Family member with Mental Health Diagnose
Individual with HIV/AIDS
Child or Children in CASA Placement
Homeless or Runaway Teen
Individual with Substance Abuse
Family or individual with open CPS/FBSS case
Individual Primary Language
English
Spanish
Other
Please tell the agency in detail what event, issue, concerns, history led the family to needing Homeless Services.
*
This will help the agency with approval process
Reason for Referral (Please give us a little detail or information about the need for housing assistance for the family or individual)
*
Select all applicable challenges below for the Individual referred (check all that apply)
Ability to avoid dangers/hazards
Anger
Anxiety
Community Linkage of Services
Daily living skills
Depression
Grief
Housing
Hygiene
Impulsive Behaviors
Juvenile Justice/Court Involved
Life Skills
Maintaining personal affairs
Medication Education
Nutritional
Phobia/s
PRTF/Hospital Discharge
Safe living situation
School behavior
Self-Advocacy Skills
Self Harm
Separation Issues
Social Skills
Substance Use
Sustainable employment
Trauma
Truancy
Whole Health/Wellness
Youth to Young Adult Transition
Other
Please understand that the mission and values of Theory Approach Inc is to decrease homelessness for families/individuals with mental health concerns or diagnoses. Theory Approach Inc P-I-E Housing Program is a Program and the families are "REQUIRED" to patriciate in services as a requirement of the program outside of FBSS/CPS services.
Theory Approach Inc
Office: 346.241.9440 (Option 2) Fax: 832.202.1349 Email: info@Theoryapproach.org
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