Second Wind Living Referral Form
Please complete this form to refer a client to Second Wind Living. We provide fully furnished, utility-included housing for individuals seeking a stable, independent living environment. We welcome applicants with diverse backgrounds and use flexible screening criteria.
Section 1: Referring Agency Information
Agency Name
*
Caseworker Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Direct Ext.
Section 2: Client Information
Client Full Name
*
First Name
Last Name
Date of Birth
*
Client E-mail
example@example.com
Client Phone Number
Current Living Situation
*
Does the client have any income?
*
Please Select
Yes
No
Pending
Prefer not to say
Gender
*
Male
Female
Race
*
African American
White
Other
Client Background (check all that apply):
*
Senior (age 55+)
Veteran
Parolee
Justice-involved
Survivor of abuse/neglect
Person with disability
Other (please describe below)
Diagnosis
*
Current Medications
*
Behaviors observed during hospitalization and/or through your involvement with the individual
*
Additional Notes or Needs:
Section 3: Referral Details
Preferred Move-In Date
*
Is this an urgent placement?
*
Yes - within 48 hours
Soon - within 1-2 weeks
Flexible
Has the client been informed about Second Wind Living?
*
Yes
No
Please upload any clinical documents
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