SteadyStep Case Manager Referral Form
Please complete the Referral form .
Case Manager Name
*
First Name
Last Name
Case Manager Email Address
*
Case Manager Phone Number
*
Case Manager Organization/Company
*
Client Name
*
Client Gender
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Female
Male
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client Email Address
example@example.com
Client Phone Number
*
example@example.com
By submitting this referral, you confirm and agree that the individual being referred is an independent adult who is able to manage their own daily living needs without assistance. This includes, but is not limited to, mobility, medication management, personal hygiene, and activities of daily living. You further acknowledge that SteadyStep LLC provides independent housing only and does not offer personal care, medical support, or custodial services of any kind.
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Yes I confirm, and Agree
No I disagree
Client's Current Living Situation
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Living w/ a friend
Living in a car
Living in a shelter
Living on the street
Incarcerated
Hospital/Facility
Group Home / Other Shared Housing
When does the client need to be placed?
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-
Month
-
Day
Year
Date
How will the client pay ?
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SSI
SSDI
VA Benefits
Full-Time Job Employment
Part-Time Job Employment
3rd party organization housing assistance
What is the Client's Current monthly Income ?
*
Does the client suffer from mental illness?
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Yes
No
If answered yes, list mental diagnoses
*
Is the client disabled ?
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Yes
No
If answered yes, list disability(s)
*
Is the client currently on any medications ?
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Yes
No
Is the client medication compliant ?
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Yes
No
Does the client require any daily assistance with personal care(such as bathing, dressing, medication management or mobility )?
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Yes
No
Does client require a Handicap Accessible living environment?
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Yes
No
Is the client a ex-offender?
*
Yes
No
Has the client been convicted of a sexual offense ?
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Yes
No
With 1000ft restriction
Without 1000ft restriction
Is the client currently on probation or parole ?
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Yes
No
Is the client in active recovery from Opioid(s) and/or other drugs and alcohol?
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Yes
No
Has the client lived in shared housing before ?
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Yes
No
When can the client pay their first month’s program fee ?
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-
Month
-
Day
Year
Date
To make sure we place the client in a unit that works best can they comfortably use stairs multiple times a day to access bedrooms on the 2nd floor (15 steps or more) ?
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Yes
No
Select all 3rd party services that the client may need external support with:
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Transportation Assistance
Job Placement
Applying for SNAP Benefits
Applying for SSI/SSDI
Organizational Payee
Health Insurance Enrollment
Clothing Donation
Cellphone/Tablet Assistance
Group Therapy
Day Program
Life Skills/Recovery Groups
I acknowledge and understand that SteadyStep LLC provides housing only. Referrals, or supportive service providers are independent, unaffiliated organizations and operate separately from SteadyStep LLC and are not under its management or control.
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Yes I understand, and acknowledge this
No I don't understand
How did you find out about us ?
*
Submit
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