New Leaf Legacy Living Referral Form
Referral form for case managers and agencies to refer individuals to the Transitional Shared Housing Program. Completion does not guarantee placement.
Referring Organization Information
Organization / Agency Name
*
Program / Department
*
Case Manager / Referral Contact Name
*
First Name
Last Name
Title
*
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Preferred Method of Contact
*
Phone
Email
Referred Individual Information
Full Legal Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email Address (if applicable)
example@example.com
Does the individual have a government-issued ID on file?
*
Yes
No
Housing Need & Referral Reason
Primary reason for referral (select all that apply)
*
Veteran transitioning to civilian life
Returning citizen reentering the community
Former foster youth aging out of care
Intern or student in workforce/education placement
Individual with fixed income (SSI, SSA, VA benefits)
Individual experiencing housing instability
Other
Brief description of current housing situation
*
Urgency of housing need
*
Immediate
Within 30 days
Flexible
Income / Stability Information
Does the referred individual have verifiable income or support?
*
Yes
No
In process
Source of income/support (select all that apply)
Employment
SSI
SSA
VA Benefits
Internship / stipend
Other
Is income expected to be stable during housing period?
*
Yes
No
Unknown
Independent Living & Community Readiness
Please confirm to the best of your knowledge (check all that apply):
*
Individual can live independently in a shared housing environment
Individual is able to manage daily self-care and personal responsibilities
Individual understands and can follow house rules and accountability standards
Individual is not currently in need of medical, mental health, or substance abuse treatment services
Safety & Compatibility Screening
To your knowledge, does the individual have a history of violent behavior?
*
Yes
No
Unknown
To your knowledge, does the individual have a sex offense history?
*
Yes
No
Unknown
To your knowledge, does the individual have active substance use that may impact housing stability?
*
Yes
No
Unknown
If yes or unknown to any of the above, please explain briefly:
Support & Ongoing Coordination
Will your organization remain involved after housing placement?
*
Yes
No
Limited follow-up
If yes, describe level of support (check-ins, case management, resources):
Referral Acknowledgment
By signing below, I confirm that the information provided is accurate to the best of my knowledge and that the referred individual has been informed of this referral.
Case Manager / Referral Contact Signature
*
Date
*
-
Month
-
Day
Year
Date
Program Disclaimer: New Leaf Legacy Living is a privately operated, unlicensed transitional support home. We are not a medical facility, treatment center, or halfway house. Placement decisions are made at the discretion of New Leaf Legacy Living to ensure community safety, program alignment, and housing stability.
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