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Serenity Haven Housing, LLC Client Referral Form
Thanks for choosing Serenity Haven Housing, LLC to partner with.
Please complete the intake form below to help us better understand the needs of the individual being referred and ensure a smooth, supportive placement process.
Referring Hospital or Agency
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
Phone Number

Area CodePhone Number
Client Name
Gender
Race
Medicaid/Medicare Status
Medical & Behavioral Information
Current Medications
Income Source (To be Verified)
Potential Move-in Date
Any Other Information
Can the client perform all personal care duties on their own?

YesNo
Thank you for providing this information. All details submitted will be used solely to assess eligibility, coordinate services, and ensure that the referred individual receives appropriate and supportive housing placement.
Upload Government Issued ID for Client

Upload a File

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