Resident Referral Form

Resident Referral Form

🌟 Thank you for taking the time to complete this referral form. Your answers will help us learn more about the resident’s needs, preferences, and circumstances so we can connect them with the housing option that feels safe, supportive, and the right fit. This form may be filled out by the resident or by someone helping them, such as a family member, hospital staff, or case manager. Please share as much detail as you can - every bit of information helps us create the best possible placement. 🧡🏡
Who is completing this form? *Please let us know if you are the resident completing this form, or if you are filling it out on their behalf. This helps us know who to contact if we have questions.
Full Name:

First NameLast Name
Email: (*Please provide a reliable email address where we can securely send updates or follow-up questions.)
example@example.com
Phone Number:
*Provide your best contact number. This should be a number where you can be reached quickly if urgent housing details need clarification.Format: (000) 000-0000.
Organization:
*If you are representing an agency, hospital, nonprofit, or care facility, please include the organization’s name. If you are a family member or friend, you may leave this blank.
Resident Name: (*Please provide the resident’s full first and last name, as it should appear in housing records.)

First NameLast Name
Age:
*Enter the resident’s age. This helps us determine the most appropriate housing type and environment.
Resident’s Phone:
*If the resident has a valid, working phone number please share it. This allows us to communicate directly if appropriate.Format: (000) 000-0000.
Resident’s Email:
example@example.com
Resident’s Preferred Location:
*Please list the city, county, or general region where the resident would prefer to live. For example, “Charleston, SC”. This helps us match them to openings that fit their location needs.
Resident's Room Preference: (*Indicate whether the resident prefers a private room, shared room, or is open to either option. If the resident strongly prefers one over the other, please select that choice.)
Type of Housing Environment Needed: (*Based on what you know, what type of housing setting seems most appropriate? If you are unsure, select “Other” and provide details so we can help guide placement.)
How Soon Is Housing Needed?
Housing Budget
Please enter the MAXIMUM amount the resident can afford per month. (*This should INCLUDE RENT AND UTILITIES.)
For shared or private room
Background / Circumstances:
(*Please describe the resident’s current situation and the reasons they need housing. The more context you share, the better we can identify the right environment. Examples: “Resident is being discharged from the hospital but cannot return to previous housing.” “Resident is currently homeless and staying in a shelter.”“Resident is in an unsafe or unstable living situation and needs immediate placement.”)
Special Needs or Accommodations:
(*List any medical, dietary, accessibility, or personal needs we should know about. Please be specific. Examples:Requires wheelchair-accessible housing (no stairs, widened doorways).Needs diabetic-friendly meals.Requires oxygen or other medical equipment.Has a service animal or emotional support animal.Needs quiet environment due to sensory sensitivities.)
ADL (Activities of Daily Living) Support: (*Please indicate how much assistance the resident requires with daily living tasks. This includes activities such as bathing, dressing, eating, using the bathroom, moving around safely, and managing medications.)
Additional Notes:
*Please share any other important details that may help us ensure the resident is placed in a supportive and appropriate environment. Examples: Resident prefers to live close to family or specific services. Gender preferences for roommates. Cultural or religious considerations. Behavioral concerns that need attention (wandering, aggression, withdrawal, etc.). Recent hospitalizations, treatments, or history that may affect housing.
Should be Empty:

Resident Referral Form

Housing Budget