LEGACY HAVEN PRIME

LEGACY HAVEN PRIME

Agency Referral Form
This form is for caseworkers, social workers, hospital discharge planners, and referral partners; submission does not guarantee placement; LHP reviews based on availability, documentation, funding, independent living ability, safety, and fit for structured shared housing.

Submission of this form does not guarantee placement. Legacy Haven Prime reviews referrals based on availability, documentation, funding verification, independent living ability, safety, and fit within a structured shared housing environment.
REFERRING PROFESSIONAL INFORMATION
Referring Agency Name
Agency/Organization Name
Referring Staff Name
Title / Role
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method

Other
APPLICANT BASIC INFORMATION
Applicant Full Name
Date of Birth

MonthDayYear
Date
Phone Number (if available)
Please enter a valid phone number.Format: (000) 000-0000.
Email (if available)
example@example.com
Current Location

Other
Veteran Status
Service Connected Status
Requested Move-in Date

MonthDayYear
Date
Preferred Room Type
FUNDING PLACEMENT AND READINESS
Funding Source (Select all that apply)

Other
Funding Approved?
Estimated Monthly Income Amount
Income Pay Date

Other
Representative Payee?
Payee Name / Contact
Third-party / Agency Payment Assistance?
Will an agency, family member, or third party assist with move-in costs or monthly membership?
If yes, who will assist and what will they cover?
Can Funding Be Verified Before Move-in?
HOUSING NEEDS AND STABILITY
Downstairs Bedroom Needed?
Mobility Limitations?
Mobility / Accessibility Details

Other
Please explain any mobility limitations or accessibility needs.
INDEPENDENT LIVING / ADL ABILITY
Independent Living / ADL Ability (check all that apply)
If applicant needs support with any daily living activities, please explain.
MEDICATION AND FOLLOW-UP INFORMATION
NOTE: Legacy Haven Prime does not administer, manage, or monitor medication dosing. This information helps determine independant living fot and placement readiness.
Currently Prescribed Medication?
Able to Self-administer?
Medication Requiring Refrigeration?
Medication Changes in Past 30 Days?
Medication Noncompliance Affected Housing/Stability in Past 12 Months?
Medication Notes
Optional; appropriate and authorized to share.
Upcoming Follow-Up appointmets?
If yes, list appointment details or follow-up needs:
Legacy Haven Prime does not administer or manage medications; this information helps assess independent living fit and placement readiness.
SHARED HOUSING COMPATIBILITY AND STABILITY
Does the applicant have any behaviors that could affect shared housing?
Known Concerns in Past 12 Months
Please explain any behavior, safety, or shared-housing concerns.
Has the applicant been violent or aggressive in the past 12 months?
Is the applicant currently medically stable for community living?
Does the applicant require 24/7 supervision, skilled nursing, detox, assisted living, or crisis stabilization?
If yes or unknown please explain:
LEGAL / PLACEMENT RESTRICTIONS
Is the applicant currently on probation, parole, or community supervision?
Is the applicant required to register as a sex offender?
Are there any location, residency, curfew, visitor, travel, or supervision restrictions that could affect housing placement?
If yes, please explain and provide supervising officer/contact information if applicable:
SUPPORT SERVICES AND CASE MANAGEMENT
Is this applicant currently working with your agency?
Type of Support Provided

Other
Will Support Continue After Placement?
Case manager or support contact, if different from referrer:
What ongoing support services will be available after placement?
EMERGENCY CONTACT
Emergency Contact Name
Relationship
Emergency Contact Phone Number (if available)
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email (if available)
example@example.com
Authorized Emergency Contact?
DIAGNOSIS / CLINICAL INFORMATION DISCLOSURE
Relevant diagnosis or clinical information that may affect housing placement, if authorized to disclose.
Share only appropriate and authorized information; LHP uses it only for placement fit, safety, and readiness.
DOCUMENTS AVAILABLE
Documents Available (Select all that apply)
Upload available documents, if applicable
ADDITIONAL NOTES AND SAFETY INFORMATION
Additional Notes and Safety Information
Referral Certification

"I confirm that the information provided is accurate to the best of my knowledge"
Referring Staff Signature (e-signature OK)
Today's Date:

MonthDayYear
Date
Legacy Haven Prime reviews referrals based on availability, documentation, funding verification, safety, independent living ability, and fit within a structured shared housing environment. Additional information, applicant interview, and documentation may be required before placement approval.
Should be Empty:

LEGACY HAVEN PRIME

REFERRING PROFESSIONAL INFORMATION

APPLICANT BASIC INFORMATION

FUNDING PLACEMENT AND READINESS

HOUSING NEEDS AND STABILITY

INDEPENDENT LIVING / ADL ABILITY

MEDICATION AND FOLLOW-UP INFORMATION

SHARED HOUSING COMPATIBILITY AND STABILITY

LEGAL / PLACEMENT RESTRICTIONS

SUPPORT SERVICES AND CASE MANAGEMENT

EMERGENCY CONTACT

DIAGNOSIS / CLINICAL INFORMATION DISCLOSURE

DOCUMENTS AVAILABLE

ADDITIONAL NOTES AND SAFETY INFORMATION

Referral Certification