Refer a Client to Still Horizon Housing
Thank you for referring a client to our sober living and transitional housing program. This form helps us understand their needs and prepare for a safe, timely placement. Please complete the form as thoroughly as possible. All information is kept confidential. If this is an urgent referral, please call us directly at 806-230-2565 after submitting.
Referring Party Full Name
*
First Name
Last Name
Organization/Agency
*
Title/Role
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Client Full Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client Gender Identity / Preferred Pronoun
*
He/Him
She/Her
They/Them
Other
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Location of Client
*
Has the client experienced domestic abuse, sexual violence, or trafficking?
*
Yes
No
Prefer not to say
If Yes, please explain the safety concerns
Are there specific safety, privacy, or emotional support needs we should be aware of? If yes please explain briefly
Reason(s) for Referral (Select all that apply)
*
Substance Use History
Mental Health Concerns
Previous Homelessness
Legal Issues
Family Reunification
Other
Desired Move-in Timeframe
*
Parole/Probation Status
*
Yes
No
Parole Officer Contact (if applicable)
Immediate Safety Concerns? (Select if applicable)
*
Yes
If Yes, please explain the safety concerns
Medical or Mental Health Needs?
*
Yes
Please specify medical or mental health needs
Client Income or Benefits Details
Upload Documentation (ID, Referral Letter, Discharge Summary, etc.)
Upload a File
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I confirm that the information provided is accurate and complete. I understand the confidentiality requirements and agree to handle sensitive health information responsibly.
*
Referring Party Signature
*
First Name
Last Name
Date of Signature
*
Hour Minutes
AM
PM
AM/PM Option
Note: For urgent referrals, please call directly at 806-230-2565 after submitting this form.
Submit Referral
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