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

Case ManagerSocial WorkerOutreach WorkerOther
Organization / Agency*
Organization / Agency (if applicable)
Phone Number*
Please enter a valid phone number.
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?*

YesNo
Client Phone Number
Please enter a valid phone number.
Current Living Situation

HomelessStaying with FriendsRecently DischargedShelterOther
Housing Preference?

Shared RoomPrivate RoomNo Preference
Client Income Source (if known)

EmploymentSSDIRetirementOther
Is the client able to manage medical needs independently?

YesNo
TIMING & NOTES

Immediate / 30–60 days / 60+ days
Additonal Notes:
CONSENT CHECKBOX (IMPORTANT)*

I confirm that I have permission to submit this referral and understand this is a non-medical Independent Living Facility (ILF).
I understand this is a non-medical Independent Living Facility (ILF) and residents must be able to manage their medical needs independently.*

Yes, I understand and AgreeNo, I do not agree
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

Client Referral Form

Referring Professional Information

Client Information