Shalom Health Enterprise – Independent Living Referral & Pre-Screening Form
This form is used to submit referrals for adults seeking independent shared housing through Shalom Health Enterprise. Submission does not guarantee placement and is used for pre-screening and waitlist purposes only.
Referring Organization / Agency Name
*
Referring Staff Name & Role/Title
*
Email address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Prospective Resident Full Legal Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Prospective Resident Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (if applicable) Not required
example@example.com
Current Housing Status
*
Please Select
Homeless
Transitional Living
Staying with Family or Friends
Independent Housing (Seeking change)
Other
Is the individual independently mobile (able to ambulate without physical assistance)?
*
Yes
No
Is the individual cognitively aware and able to make independent decisions regarding daily living?
*
Yes
No
Does the individual require hands-on personal care, medical care, or 24-hour supervision?
*
Yes
No
Does the individual currently have a stable source of income?
*
SSI
SSDI
Veterans Benefits
Pension
Employment
Other
No current income
Is the individual compliant with medications and case management services (if applicable)?
*
Yes
No
Not Applicable
Has the individual been diagnosed with any condition requiring a higher level of care than independent living?
*
Yes
No
Would the individual benefit from a structured, accountability-based living environment?
*
Yes
No
Has the individual lived successfully in a shared housing environment before?
*
Yes
No
Not sure
Are there any known behaviors or concerns that may impact a shared living environment?
*
Yes
No
I understand that Shalom Health Enterprise is currently in the process of securing residential housing. This referral is for pre-screening and waitlist placement only. Residents will be prioritized and prepared for placement once housing becomes available.
*
Acknowledged
I certify that the information provided is accurate to the best of my knowledge and consent to the review of this referral for independent living placement consideration. (Referring staff signature)
Date Submitted
-
Month
-
Day
Year
Date
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