Onyx Group Atlanta, Housing Referral Interest Form (Providers)
This form is for housing interest and referrals only and does not guarantee immediate placement.
Section 1, Referral Source Information
Referral Partner Name
*
Referral Partner Organization
*
Referral Partner Title
*
Referral Partner Email
*
example@example.com
Referral Partner Phone
*
By submitting this form and providing your phone number, you agree to receive SMS messages from ONYX GROUP ATLANTA regarding housing inquiries, application and intake updates, appointment scheduling, and account related updates. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out at any time or HELP for assistance. SMS consent and phone numbers will not be shared with third parties for marketing purposes. For more information, please review our Privacy Policy: https://www.onyxgroupatl.com/privacy-policy/
Referral Source Type
*
VA case management
HUD VASH
Hospital or discharge planning
Behavioral health or community clinic
Nonprofit housing services
Reentry or Justice Involved Services
Other
Section 2, Participant Information
Client Name
*
Client Phone
*
Client Email
example@example.com
Client Age Range
*
21-30
31-40
41-50
50 or greater
Section 3, Housing Fit
Is the participant able to live independently without clinical or assisted living support?
*
Yes
No
Unsure
Is Ambulatory
*
Please Select
Yes
No
Unsure
Cognitively Aware
*
Yes
No
Unsure
Cognitively Aware
Please Select
Yes
No
Unsure
Current Living Situation
*
Please Select
Hospital
Program or treatment center
Shelter
Transitional housing
Living with family or others
Unsheltered
Jail or correctional facility
Recently released, temporary placement
Other
Income Stable & recurring monthly
*
Please Select
Yes
Pending or unstable
Unknown
Primary Income Source
*
Please Select
HUD VASH voucher
Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI)
VA benefits or Pension
Social Security Retirement
Employment income
Other
Estimated Monthly Income
Desired Move In Timeframe
*
Immediately
Within 30 days
Within 60 days
Flexible or unknown
Section 4, Additional Information
Any relevant information or considerations we should be aware of
*
Section 5, Confirmation
I confirm that this referral is appropriate for independent shared living housing and that the participant is aware of this referral.
*
I Confirm
Submit
Should be Empty: