Legacy Housing Partners - Agency Referral Intake Form
Referral Website: https://www.legacyhousingpartners.com/referrals
SECTION 1: REFERRING AGENCY INFORMATION
Agency Name:
*
Program / Department Name:
*
Agency Address:
City / State / Zip:
*
Primary Contact Name:
*
Title:
*
Phone Number:
*
Email Address:
*
example@example.com
Secondary Contact (if applicable):
Best Method of Contact:
Phone
Email
SECTION 2: REFERRAL TYPE
Referral Type Options
*
Emergency Placement Needed (0-7 days)
Standard Placement (7-30 days)
Housing Navigation / Matching Only
Veteran-Specific Placement
Re-Entry / Returning Citizen Placement
Senior (55+) Placement
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SECTION 3: CLIENT INFORMATION
You can submit information for additional clients after you have completed this initial intact form
Client Full Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
Gender Identity
*
Please Select
Female
Male
Phone Number (if applicable):
*
Email (if applicable):
example@example.com
Preferred Method of Contact:
*
Phone
Email
Case Manager Only
Date ready to move in:
*
-
Month
-
Day
Year
Date
SECTION 4: POPULATION & ELIGIBILITY DETAILS
Specific information for this client
*
Single Adult
Senior (55+)
Veteran
Re-Entry / Returning Citizen
Veteran Status (if applicable):
*
Active VA Benefits
HUD-VASH Eligible
Veteran -
Benefits Pending
Not Applicable
Re-Entry Details (if applicable): Release Date:
*
-
Month
-
Day
Year
Date
Supervision Type:
*
Probation
Parole
None
SECTION 5: INCOME & FINANCIAL INFORMATION
Current Monthly Income Amount:
*
Income Source(s):
*
SSI / SSDI
SSA / Retirement
Employment
Veteran Benefits
Pension
No Income
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Ability to Pay Monthly Room Fee:
*
Yes
No
Partial
Third-Party Payor (if applicable):
SECTION 6: HOUSING NEEDS & PREFERENCES
Housing Type Requested (check all that apply):
*
Room-Only / SRO
Shared Housing
Transitional Housing
Preferred Location:
*
Duval County Only
Surrounding Counties
Accessibility Needs:
*
Ground Floor
ADA Accessible
None
Smoking Preference:
*
Smoker
Non-Smoker
SECTION 7: HEALTH & SUPPORT CONSIDERATIONS
Does the client require ongoing case management?
*
Yes
No
Behavioral Health Diagnosis (if applicable):
*
Yes
No
Medication Managed Independently:
*
Yes
No
History of Violence or Arson:
*
Yes
No
Active Substance Use:
*
Yes
No
(Note: This information is used for appropriate housing matching only.)
SECTION 8: DOCUMENTATION STATUS
Documentation Status
*
Government ID
Social Security Card
Proof of Income
Release of Information (ROI)
Background Check (if available)
Veteran DD-214 (if applicable)
SECTION 9: REFERRAL CERTIFICATION
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By submitting this referral, the referring agency certifies that the information provided is accurate to the best of their knowledge and that the client is appropriate for shared or room-only housing placement.
Referring Staff Name:
Signature:
Date:
-
Month
-
Day
Year
Date
SECTION 10: LEGACY HOUSING PARTNERS - INTERNAL USE ONLY
Date Received:
-
Month
-
Day
Year
Date
Assigned Housing Specialist:
Placement Status:
Pending
Matched
Placed
Not Eligible
Notes:
Submit completed referrals via: https://www.legacyhousingpartners.com/referrals
For questions, agencies may contact Legacy Housing Partners through the website intake portal.
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