The Kingsley Group Client Referral Form

The Kingsley Group Client Referral Form
I. Client Referral FormI.

Referral Source Information.
Who is submitting this request?

Referral: First NameReferral: Last Name
Agency/Organization:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
II. Client Basic Information
Full Legal Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Gender:
Current Location: (e.g., Hospital, Shelter, Street, Family)
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Does the client have a ID/Social Security Card?

YesNo
Relationship to Client:
Business Email
example@example.com
Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you like to be contacted?

EmailPhone
What services does your Housing offer?
What population is your business looking to house.

VeteranElderlyMental HealthDrug and AlcoholReentryDomestic ViolenceThose experiencing hardshipWomen and childrenOthers
Do you accept pets.

YesNo
How many shared rooms beds do you have available?
How many private rooms do you have available?
When can a client move in?

24hrs48hrs1 Week2 WeeksASAPOther
When can a client move in?

MonthDayYear
Date
Do you provide transportation if needed?

YesNo
If yes, do the client have to pay back transportation cost?

YesNoOther
What is the coast of shared room?
What is the cost of private rooms?
Referral Partner agrees to inform Kingsley Group about the status and outcome of the referral clients prior to move in date.

YesNo
III. Clinical & Support Needs.
Primary Population Category:

VeteranSeniorMental HealthRe-entrySubstance RecoveryPhysicalDisability
Mobility Status:[ ] Independent [ ] Uses Walker/Cane [ ] Wheelchair Accessible Required

IndependentUses Walker/CaneWheelchair Accessible Required
Level of Care Needed:

Independent LivingShared Housing w/ SupervisionAssisted Living Style
Medication Management:

Self-AdministersNeeds RemindersNeeds Full Administration
IV. Housing Preferences & Logistics
Room Preference:

Shared Room (Lower Cost)Private Room
Desired Move-In Date:

MonthDayYear
Date
Does the client have pets? [If yes, breed/size: _____________________)

YesNo
Is transportation required for move-in?

YesNo
Funding Source: Other: ___________________________________

SSI/SSDIPrivate PayVA BenefitsSection 8/VoucherOther: ___________________________________
V. Behavioral & Safety Screening
Active Substance Use? If yes, last use date: _______________

YesNo
History of Violence/Arson?

YesNo
Registered Sex Offender?

YesNo
Are there any specific "triggers" or behaviors our staff should be aware of?
The Referral Partner commits to maintaining open communication, ethical practices, and the confidentiality of all referred clients throughout the process. Kingsley Group will review the information provided to determine the potential participant's eligibility for services.
Should be Empty:

The Kingsley Group Client Referral Form

I. Client Referral FormI.

II. Client Basic Information

III. Clinical & Support Needs.

IV. Housing Preferences & Logistics

V. Behavioral & Safety Screening