Referral Intake Form
For referring clients to New Leaf Legacy Living's transitional housing program
Client Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Referral Organization
*
Case Manager / Discharge Planner Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Population Type
*
Please Select
Veteran
Returning citizen
Former foster youth
Intern/student
Fixed-income adult
Individual seeking a fresh start
Other
Primary Income Source
*
Please Select
SSI/SSDI
Employment
Pension/Retirement
Public Assistance
Family/Friends Support
Placement Plan Pending
Other
Referral Urgency
*
Immediate (within 24 hours)
High (1-3 days)
Routine (within 1 week)
Independent Living Readiness
*
Able to live independently in shared housing
Needs minimal support
Not independent (not eligible)
Estimated Length of Stay
*
Please Select
Less than 1 month
1-3 months
3-6 months
6+ months
Undetermined
Additional Notes (medical stability, housing needs, special considerations, etc.)
Referring Staff Signature (sign below)
*
Submit Referral
Submit Referral
Should be Empty: