Clone of Resident Housing Application

Where Independence Meets Choice

Thank you for submitting a client referral.Please complete this form with the available information. Our team will review the referral and reach out regarding next steps based on availability.
Client Referral Form

For case managers, social workers, and outreach professionals submitting a referral on behalf of a client.
Referring Professional Information

Please provide your information as the referring case manager, social worker, or outreach professional.
Referring Professional Name

First NameLast Name
Role/Title
Organization / Agency
Organization / Agency (if applicable)
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Client Information
Client Name

First NameLast Name
Client Date of Birth

MonthDayYear
Date
Is Client 18 years of age or older?
Client Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Living Situation

Other
Housing Preference?
Client Income Source (if known)

Other
Is the client able to manage medical needs independently?
TIMING & NOTES
Additonal Notes:
CONSENT CHECKBOX (IMPORTANT)
I understand this is a non-medical Independent Living Facility (ILF) and residents must be able to manage their medical needs independently.
Important Notice
K&M Choice Living is a non-medical Independent Living Facility (ILF).
Submission of this application does not guarantee housing placement.
Housing availability is based on eligibility and space.
Should be Empty:

Where Independence Meets Choice