• Vella Haven Village

    Complete this form to refer an individual for housing consideration with Vella Haven Village. Our team will review the information provided and follow up regarding eligibility, availability, and next steps.

  • Referral Information

  • Format: (000) 000-0000.

  • Applicant Information

  • Applicant Gender*
  • Format: (000) 000-0000.
  • Is it okay to leave a voicemail?
  • Format: (000) 000-0000.
  • Do we have permission to text/leave a message on the number provided ?*
  • Date Of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Current Housing Situation

  • What is theApplicant's Current Living Situation*
  • When does Applicant need to be placed?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • How will the applicant pay ?*
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  • Do you have a Mental Illness ?*
  • Does client require a Handicap Accessible Living environment*
  • Is the Client an ex-offender*
  • Are you currently on Probation or Parole ?*
  • Do you need help with recovering from Opioid(s) and/or other drugs and alcohol?*

  • Income, Employment & Education

  • Income Source(s)
  • Is income verification available?
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  • Interested in employment assistance?
  • Interested in education or job training?

  • Independent Living & Accessibility

  • Can the applicant independently manage personal care and daily living needs?*
  • Can the applicant independently manage their medications, if applicable?*
  • Does the applicant require daily medical supervision?*
  • Does the applicant require assistance with activities of daily living?*
  • Does the applicant need an accessible living environment or reasonable accommodation?*
  • How did you hear about us*

  • Health & Level-of-Care Screening

  • Does the applicant currently require inpatient medical, mental-health, or substance-use treatment?*
  • Does the applicant currently require detoxification services?*
  • Is the applicant able to manage prescribed medications independently?*
  • Are there current health, behavioral-health, or recovery support needs Vella Haven should consider when determining an appropriate placement or referral?*
  • Would the applicant like help connecting with behavioral-health or recovery resources?*

  • Reentry & Legal Information

  • Is the applicant currently returning to the community after incarceration or otherwise justice-involved?*
  • Expected/Actual Release Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Currently on Probation or Parole?
  • Are there housing/location restrictions that may affect placement?

  • Program Fit

  • Please confirm the applicant understands that Vella Haven Village provides structured shared housing.*

  • Support Requested

  • Select all of the services you are requesting .*

  • Consent, Additional Information & Submission

  • Permission to Communicate With Referral Source- I give Vella Haven Village permission to communicate with the referring professional/organization regarding this referral, eligibility, placement, and appropriate next steps.
  • Should be Empty: