Luxe Haven's Referral Form Assessment

  • Luxe Haven's Referral Assessment

    We value your input - your answers matter. Please answer as clearly and honestly as possible, as sharing accurate details helps us create the best possible experience for your referral.
  • Date*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Client Date of Birth*
     - -
  • Gender*
  • Martial Status*
  • If they are in transition, please let us know which of the following best reflects their situation.*
  • Are they currently employed?*
  • Do they have a reliable source of income to cover the program fee, monthly room charges (shared or private), and their personal expenses each month?*
  • What is their source of income?*
  • Do they have a secondary source of income?*
  • Are they a veteran?*
  • Which type of room are they applying for?*
  • How soon are they planning to move?*
  • Will they be the only person participating in the program or will there be someone else accompanying them?*
  • Do they have or plan to bring any pet(s) with them?*
  • Do they require any daily assistance with personal care? (i.e. bathing, dressing, medication management, or mobility)*
  • If they are prescribed medications, do they take them independently? Please note: Luxe Haven is not a medical facility and cannot administer medication.*
  • Do they have any physical limitations or accessibility needs, or require medical supervision or specialized services to live safely day to day?*
  • Can they independently handle daily tasks such as meals, laundry, and cleaning their living space?*
  • This program is designed for independent adults only. It is not an assisted living, group home, or medical housing program. Do you/client acknowledge and understand this requirement?*
  • Are they comfortable living in a shared home community where common areas such as the kitchen, bathroom, living and laundry rooms, are used by other members in the residence?*
  • Are they comfortable sharing a semi-private bedroom with at least one other resident?*
  • Do they agree to follow all program rules, including quiet hours, visitor policies, and cleanliness standards?*
  • Have they ever been asked to leave a residence due to behavior, rule violations, or disturbances?*
  • To ensure we place them in the most suitable unit, are they able to safely and comfortably use stairs to reach bedrooms on the second floor?*
  • Have they ever been convicted of a violent crime or property damage? Please note, answering 'Yes' does not automatically disqualify them.*
  • Have they ever been convicted of a sexual offense? Please note, answering 'Yes' does not automatically disqualify them.*
  • Do they have any pending criminal or sexual convictions pending? Please note, answering 'Yes' does not automatically disqualify them.*
  • Our residences are alcohol and drug free (including marijuana). Are they able to comply with this requirement?*

  • Thank you for completing this referral assessment- together, we're building brighter futures, one haven at a time.

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