Referral & Partnership Form
Independent Living Community (Non-Medical Housing)
Virtuous Legacy LLC provides housing only and does not offer medical care, personal assistance, or case management services.
SECTION 1: ORGANIZATION / AGENCY INFORMATION
Organization / Agency Name:
Program or Department Name (if applicable):
Primary Contact Person:
Title:
Phone Number:
Email Address:
example@example.com
Mailing Address:
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SECTION 2: PARTNERSHIP TYPE
Please indicate the purpose of this referral or partnership (check all that apply):
Please indicate the purpose of this referral or partnership (check all that apply):
Housing referral for client/participant
Ongoing referral partnership
Re-entry support referral
Veteran housing referral
Community or faith-based partnership
Other
SECTION 3: REFERRED INDIVIDUAL INFORMATION
(If referring a specific individual)
Full Legal Name:
Date of Birth:
Phone Number (if available):
Current Housing Status:
Current Housing Status:
Homeless
Transitional housing
Institutional discharge
Staying with family/friends
Other
SECTION 4: INDEPENDENT LIVING ELIGIBILITY CONFIRMATION
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Please confirm the following by checking each box:
Individual is 18 years or older
Individual is able to live independently
Individual does NOT require medical care
Individual manages their own medications
Individual can perform activities of daily living independently
Individual understands this is shared, non-medical housing
SECTION 5: SUBSTANCE & BEHAVIORAL DISCLOSURE
Virtuous Legacy LLC is a drug- and alcohol-free housing environment.
Please confirm:
Individual is not currently using illegal substances or alcohol
Individual agrees to a no illegal substance and no alcohol policy
Individual understands violations may result in immediate termination
If there are concerns related to substance use or behavioral history that may impact shared housing, please briefly explain (optional):
SECTION 6: INCOME & HOUSING STABILITY
Does the individual have a verifiable income source?
Yes
No
Pending
Source of Income (if known):
Employment
SSI / SSDI
Veteran Benefits
Pension
Public Assistance
Other
Estimated Monthly Income (if known): $
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SECTION 7: PARTNERSHIP EXPECTATIONS(IMPORTANT)
Please acknowledge the following:
Please acknowledge the following:
Virtuous Legacy LLC provides housing only
Referring agency remains responsible for case management, if applicable
Virtuous Legacy LLC does not provide medical or behavioral services
Placement is subject to availability and intake approval
SECTION 8: AGENCY CERTIFICATION &ACKNOWLEDGMENT
I certify that the information provided is accurate to the best of my knowledge and that the referred individual is appropriate for non-medical independent living housing.
Agency Representative Name:
Signature:
Date:
-
Month
-
Day
Year
Date
SECTION 9: NEXT STEPS
After submission:
Virtuous Legacy LLC will review eligibility
Intake or tour may be scheduled
Final placement is subject to approval and availability
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