Referral Form

Referral Form
Your Full Name: (Referring Provider)*

First NameLast Name
Your Organization Name:*
Your Role / Title:*
Your Email:*
Your Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about Home Sweet Home Housing Solutions?*

FacebookGoogleSocial WorkerCase ManagerCommunity EventFlyer or BrochureWord of mouthOther
If "Community Event", please specify name of event. Otherwise, put N/A.*
Client Name*

First NameLast Name
Client date of birth*

MonthDayYear
Date
Client Age*
Client Gender*

MaleFemaleTransgender
Client Phone Number (Enter all zeroes if client does not have a phone)*
Please enter a valid phone number.Format: (000) 000-0000.
Current Location (City & State)*
Current Living Situation*

ShelterLiving on the streetLiving in their carStaying with othersTransitional housingAssisted Living FacilityHospital / RehabJail ReleasePrison ReleaseOther
If “Hospital / Rehab”, what is their anticipated discharge date?

MonthDayYear
Date
Is the client aware of this referral?*

YesNo
Is the client currently on supervision?*

ParoleProbationNeither
Does the client have any history of violent or sexual offense?*

YesNo
Any pending legal charges?*

YesNo
If yes to history of violent or sexual offense OR supervision or legal background, please explain. If no to the above, put N/A.*
Has the client ever been diagnosed with a mental health condition?*

YesNo
If yes, please specify condition and current treatment plan:*
Does the client have any of the following chronic illnesses or health conditions?*

Heart DiseaseStrokeCancerDiabetesHypertension (High Blood Pressure)Kidney DiseaseDialysisHIV / AIDSBlindnessAmputeeNo health conditionsOther
Does the client have any behaviors?*

YesNo
If yes, please explain:*
Is client compliant with taking their medication(s)?*

YesNo
If no, what is their reason for non-compliance?*
Substance use history?*

YesNo
If yes, what is their substance of choice and when was the last time they used?*
Currently sober?*

YesNo
If yes, how long?*
If no, what is their drug(s) of choice and when did they last use?*
Is the client open to a structured shared living independent environment?*

YesNo
Income Source ( Check all that apply)*

SSISSDIVA BenefitsRailroad BenefitsEmploymentOther retired or disability benefits
If "Other retired or disability benefits", please specify. If no other benefits, put N/A.*
Total Monthly Income Amount:*
Does the client have: (Check all that apply)*

Emergency ContactValid IDSocial Security NumberSocial Security CardProof of IncomeMedicaidMedicareOther InsuranceBirth CertificateDebit CardRepresentative Payee
Does the client receive food stamps?*

YesNo
Does the client require assistance with any of the following below? (Check all that apply)*

No assistance requiredBathingDressingGroomingEatingWalkingTaking your medicationToileting
Does the client require grab bars for the shower?*

YesNo
Does the client require a shower chair?*

YesNo
Does the client use any of the adaptive equipment below? (Check all that apply)*

IndependentCaneWalkerRollatorWheelchairOther
If "Other", please explain:*
Does the client have incontinence issues?*

NoYes, urine onlyYes, bowel onlyYes, urine and bowel
Does the client require a special diet?*

YesNo
If yes, please explain:*
Is the client able to prepare their own meals?*

YesNo
Any other accommodations needed?*

YesNo
If yes, please specify:*
Reason for wanting placement with Home Sweet Home Living Solutions?*
Do you have any additional notes or concerns?*
What is the client's preferred move-in date?*

MonthDayYear
Date
Consent

By entering my name below, I acknowledge the information provided is accurate to the best of my knowledge and I consent to its use for the purpose of my application. I also understand the health information I provided is under the protection of the federal Health Insurance Portability and Accountability Act (HIPAA). We can use this information for the purpose of applying to our program. With this encrypted form, your information is protected.
Name*

First NameLast Name
Date Signed*

MonthDayYear
Date
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