Lawrence Community Shelter Referral to Shelter Services

Lawrence Community Shelter Referral to Shelter Services
If you would like someone to be considered for our services, please go through the referral and approval process. We understand that the need is high and resources are limited. Out of county/state residents or drop-offs from other agencies will not be accepted without prior approval.

Please complete the form and referrals will be evaluated as our programs have availability. Any Douglas County resident may seek shelter in our Night by Night Program (7pm-8am) as long as they are able to meet the LCS Expectations.

We are unable to serve individuals that cannot meet their own basic care needs such as performing their own personal hygiene, toileting unassisted, eating unassisted, dressing unassisted, undressing unassisted, and ambulating/navigating the building and surrounding area unassisted.

Thank you.
1. Your Name

First NameLast Name
Email
example@example.com
Agency and Title
2. Referral Name

First NameLast Name
Contact Information

Email (example@example.comPhone Number
Date of Birth

MonthDayYear
Must be 18 or older.
3. Is the individual a Douglas County resident? *

YesNo
4. If they are not a Douglas County resident what connections supports or resources do they have available to them in Douglas County? (enter NA if not applicable)
5. Is the individual currently unsheltered or staying in a place not intended for human habitation?

YesNoNot Sure
6. Is the individual currently obtaining services in our night by night shelter program?

YesNoNot Sure
7. Has the individual been entered into Clarity?

YesNoNot Sure
8. Does the individual have a completed CES Assessment?

YesNoNot Sure
If Yes, what was their score and when was the assessment conducted? (Please put "N/A" if not applicable of "Not Sure" if unknown)
9. Does the individual have any physical, mental, or behavioral vulnerabilities or barriers to housing or other services?

YesNoNot Sure
10. What barriers to housing or services does the disability or vulnerability create?
11. Does the individual meet the definition of chronically homeless? (Chronic homelessness is used to describe people who have experienced homelessness for at least a year — or repeatedly — while struggling with a disabling condition such as a serious mental illness, substance use disorder, or physical disability.)

YesNoNot Sure
12. Does the individual meet any of the following criteria?

VeteranSenior (55 or over)Documented DisabilityFleeing or Survivor of Domestic Violence
13. Please provide details on the selected criteria above and/or define other if selected:
14. What agencies and community partners is the referral working with?

Bert Nash Community Mental Health CenterCity Team (Lawrence Homeless Solutions)DCCCADCSO ReentryFamily PromiseHaskell Indian Health CenterHeartland Community Health CenterLawrence Community ShelterLawrence Humane SocietyRed CrossRADACVeterans AffairsThe WillowWork for SuccessOther
Please define "Other" of applicable. Enter "NA" if not.
15. Will this individual be receiving ongoing case management or wraparound services? If so, please provide contact information for the agency or individual that will be working with them.
16. Why do you think this client would benefit from the 90 day continuous stay program vs staying night by night? (Night by night services run from 7pm-7am while continuous stay is a 24 hour sheltering program. We also do accomodate for overnight workers with a day by day program of 7am to 7pm.)
17. Is there anything else you would like for us to know or consider?
Please also fill out and upload the linked forms in the upload section below:

3rd Party Homeless Verification Referral - https://tinyurl.com/3rdpartyref

Community Partner ROI - https://tinyurl.com/compartroi
Please upload the pdf's listed in the description here.:

Cancelof
Thank you for your referral.
Should be Empty: