Pre-Check Eligibility Form

Pre-Check Eligibility Referral Form

This form helps determine if RAD Supportive Living may be a good fit. Submitting this form does not guarantee placement.
Referring Agency / Case Manager Name Phone / Email *
Name of the person you are referring*

First NameLast Name
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
SECTION 1 – Basic Eligibility *

I am 18 years or olderI am seeking stable housingI can live independently with light supportI am willing to follow house rulesI am willing to participate in check-ins
SECTION 2 – Housing Readiness *

I do not require 24/7 medical careI do not require a group home settingI do not require emergency shelterI can manage daily living tasks independently
SECTION 3 – Income & Rent Do you have an income source? Income Source (employment, SSI, SSDI, agency, etc.) *

YesNo
SECTION 4 – Program Fit *

I am not a registered sex offenderI do not have recent violent felony convictionsI am not actively using substances without treatmentI do not require locked or clinical supervision
SECTION 5 – Support Needs *

Employment assistanceEducation or trainingBudgeting or life skillsCase management coordinationTransitioning from shelter/program
SECTION 6 – Referral Source How did you hear about RAD Supportive Living?*

SelfCase Manager / AgencyShelterTreatment ProgramOther
SECTION 7 – Consent & Acknowledgment *

I certify the information provided is accurateI understand this is a pre-screen, not an applicationI give permission to be contacted by RAD Supportive LivingI understand submission does not guarantee acceptance
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Pre-Check Eligibility Referral Form