Housing Stabilization Support Referral Form

Housing Stabilization Support Referral Form
Is there another possible HSS provider*

YesNo
If Yes, please add provider Contact Info below
Submission Type*

Initial (Over 30 Days Expired or First Time Utilizing Housing Stabilization Support Services.)Change Request (Over 30 Days Expired or First Time Utilizing Housing Stabilization Support Services.)
Type of support needed*

TrasitioningSustaining
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender Identity
Address
Contact Number*
Email Address
Religious & Cultural Preference(s)
Language(s) Spoken
Cultural Considerations
Race/Ethnicity
Disability Type (please check all that apply)*

Mental IllnessSSI/SSIDDevelopmental DisabilitySubstance Use DisorderInjury or Illness with Extended IncapacitationLearning Dissability
Medical Equipment, Devices, Adaptive Aides or Technology.
Guardian Status*

Self Guardian 1PrivatePublicUnder Commitment
Housing Instability*

HomelessAt Risk of HomelessnessTransitioning from FacilityInstitutional Level of Care/Waiver Eligible
Current Living Situation*

Own housing: Lease, Mortgage or RoommateService Provider: Foster Care or Group HomeJail/Prison/Juvenile DetentionFamily/Friends due to Economic HardshipHospital/Treatment/Detox/Nursing HomeEmergency ShelterHotel/MotelA Place not meant for Housing
Does this person currently have a source of income?*

YesNo
If yes, what types of Income?
Is this person currently homeless?*

YesNo
If yes, for how long?
Does this person have any mobility concerns?*

YesNo
Does this person currently have a lease?*

YesNo
If yes, when will the lease end?
How soon does this person want/need to move?*
Does this person use any of the following to assist with mobility?

CaneWalkerWheelchairScooterOther
Will this person need transitional services? (select all that apply)*

DepositMoversHousehold ItemsFurniture
Will there be moving expenses?

YesNo
How did you hear about Everest Healthcare Services?*
Please verify that you are human*
Should be Empty: