Community Connection Application
Please complete this form to refer a client for supportive housing and stability services through Anchor Haven Solutions. This secure form is designed for social workers, case managers, and community partners. Once submitted, our intake team will review the referral and follow up within 24–48 hours to begin the placement process.
Referral Source Information
Agency / Organization Name
Referring Agency/Organization
Referrer’s Name and Title
Professional Email Address
example@example.com
Direct Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact:
Email
Phone
Your Role / Relationship to Client
Client Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Support Needed
Housing
Recovery Support
Client's Current Living Situation
Homeless
Shelter
Transitional Housing
With Family and Friends
Preferred Move-In Date
-
Month
-
Day
Year
Date
Does the client have a source of income or housing assistance (such as a voucher or program support)?
Yes
No
Our homes are tobacco-, alcohol-, and drug-free. Is the client you are referring willing to follow these guidelines while residing in the program?
Yes
No
Does the client have the ability to live independently with minimal assistance?
Yes
No
What type of housing is the client interested in?
Private
Shared
Preferred Contact for Next Steps
Please select who should receive follow-up communication about eligibility, interviews, or next steps.
Who should we contact regarding this referral?
The Client
The Case Manger/Social Worker
Both
How Did You Hear About Us?
We are always interested in partnering with individuals and agencies who share our mission. Letting us know how you heard about us helps us show appreciation to our partners and identify opportunities to grow within the community.
How did you hear about Anchor Haven Solutions?
Case Manager or Social Worker
Community Partner or Organization
Referral from Current/Previous Client
Online Search/Google
Flyer or Event
Social Media
Other
Consent & Acknowledgment
*
I confirm the above information is accurate to the best of my knowledge and that the client is aware of this referral.
Submit
Should be Empty: