TDCJ 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
Unit Name
*
Reentry Contact
*
First Name
Last Name
E-mail
*
example@example.com
Direct Phone Number
*
Direct Ext.
Section 2: Client Information
Client Full Name
*
First Name
Last Name
Date of Birth
*
Gender
*
Male
Female
Race
*
African American
White
Hispanic
Other
Primary Language
*
Mental CapacityIs the individual able to make sound decisions independently?
*
Level of Care: Can the individual independently manage activities of daily living (bathing, grooming, toileting, eating, transferring)? If not, please specify which ADLs require assistance.
*
Is the individual a U.S. citizen?
*
Yes
No
Please select what documentation the individual will be released with?
*
State ID
Social Security Card
Birth Certificate
Veteran Status: Is the individual a veteran?
*
Yes
No
SSI/SSDI Status: Has the individual been approved for or reinstated on SSI/SSDI? Are there any outstanding obligations to Social Security? (If an application has been submitted, please share the current status.
*
Medical and Mental Health: Are there any major medical conditions or known mental health diagnoses?.
*
Medication: Is the individual currently taking any medication?
*
Yes
No
Mobility: Do they use any mobility aids (walker, wheelchair, rollator, cane)?
Discharge Type: Is the discharge flat or parole? If on parole, please include the duration.
Charges
*
Anticipated Discharge Date
*
Additional Notes or Needs:
Section 3: Referral Details
Has the client been informed about Second Wind Living?
*
Yes
No
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