Champaign House Referral
This form is to be used by case managers, social workers, housing advocates, and CSPH providers to refer clients living with HIV/AIDS to GCAP's HOPWA housing program, "Champaign House".
Client name
*
First Name
Last Name
Referring person's name
*
First Name
Last Name
Referring person's agency
*
Referring person's phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring person's email
*
example@example.com
Date of Referral
*
/
Month
/
Day
Year
Date
Has the person making this referral completed the Treatment Plan Client Information Form for the client?
*
Yes
No
The Treatment Plan Client Information Form will need to be completed for the referral to be valid. Please mark yes to acknowledge this is required, and referral will be denied if the form is not completed.
*
Yes
No
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Is the client a sex offender subject to a lifetime registration requirement under a State sex offender registration program (24 CFR 960.204, 24 CFR 982.553)
*
Yes
No
Is the client a sex offender who has been prohibited from going within 500 feet of a school or school property, public park, or day-care center.
*
Yes
No
Was the client ever found to have manufactured or produced methamphetamine on the premises of federally assisted housing (24 CFR 960.204, 24 CFR 982.553)?
*
Yes
No
Unknown
Does the client have current or previous drug use?
*
Yes
No
Currently
In the past MONTH how often has the client used tobacco or smokeless tobacco?
*
Never
Rarely
Sometimes
Often
Frequently
Other
In the past MONTH how often has the client used alcohol?
*
Never
Rarely
Sometimes
Often
Frequently
Other
In the past MONTH how often has the client used use marijuana (weed; blunts)?
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Never
Rarely
Sometimes
Often
Frequently
Other
In the past MONTH how often has the client used Cocaine or crack, heroin, amphetamines or methamphetamines (non-medication), hallucinogen (e.g., magic mushrooms, lsd, etc.), inhalants (e.g., huffing gasoline, glue, nitrous oxide, etc.?
*
Never
Rarely
Sometimes
Often
Frequently
Other
Does the client's drug abuse and/or alcohol abuse threaten the health, safety, or right to peaceful enjoyment of the premises by other residents?
*
Yes
No
N/A
Other
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Are there any identified, past or current, domestic violence issues?
*
Yes
No
Currently
Is the client's housing situation a result of domestic violence?
*
Yes
No
Is the client a Veteran, (anyone who has been on active military duty)
*
Yes
No
Does the client have a serious mental health issue or has the client been determined SMI (Seriously Mentally Ill) by a provider?
*
Yes
No
Other
Does the client have any disabilities that require use of mobility equipment?
*
Yes
No
Does client need a first floor, accessible room?
*
Yes
No
Does the client have family members who are needing to live with them?
*
Yes
No
If yes, please provide name, relationship to client, date of birth, SSN, and gender for each family member
*
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Is the client at current risk for homelessness?
*
Yes
No
Currently homeless
Please describe circumstances
*
Length of homelessness this episode:
*
Not homeless at present
Less than 1 month
At least 1 month
At least 1 year but less than 2 years
2 years but less than 3
3 years or more
Number of episodes in the past 5 years
*
Approximate number in lifetime
*
Within the last four 4 years how many nights, months, or years if any has client spent in a shelter
*
Where has client slept for the last thirty (30) days? Check all that apply.
*
Emergency Shelter
Transitional housing
Hospital, psychiatric facility, prison, or rehab center
With friends/family
In an apartment/house that you rent
In an apartment/house that you own
In an apartment/house that is subsidized
Motel paid for by housing assistance provider
Motel or hotel paid for by self
In space not meant for human habitation (car, abandoned building, alley)
Reason for leaving previous housing situation
*
Eviction due to unpaid rent
Eviction due to reason other than unpaid rent
Conflict with friends or family
Domestic violence
Overcrowding
Incarceration
Hospitalization
Natural disaster
Condemed
Other
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Does client have a current HIV provider?
*
Yes
No
Does client have a current PCP?
*
Yes
No
Is client currently undetectable?
*
Yes
No
Is client currently engaged with Ryan White services at C-UPHD?
*
Yes
No
What is their Ryan White number?
*
Is there anything else we should know about the factors contributing to this clients current housing needs? If clients current need is urgent and related to safety, health, mental health, etc. please note that here.
*
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Please upload proof of HIV
*
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Please upload Identification
*
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Submit Referral for Champaign House
A GCAP staff member will contact you regarding this referral within one week. Please contact casemanager@gcapnow.com if you have any questions or concerns
Case Manager Name
*
First Name
Last Name
Case Manager Signature
*
Date
*
-
Month
-
Day
Year
Date
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