Section 1: Referral Source Information
Welcome, Referral Partners
Thank you for considering ONYX GROUP ATLANTA. Please complete this brief form so our team can quickly assess housing fit and coordinate next steps.
Referral Partner Name
*
Would you like ONYX GROUP ATLANTA to reach out to the participant directly, or should we contact you instead?
*
You may contact the participant directly
Please contact me instead
Please contact someone else
Alternate Contact Name
*
Alternate Contact Phone
*
Would you like Onyx Group Atlanta to reach out to the participant directly, or should we contact you instead?
*
You may contact the client directly
Please contact me instead
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
Participant Name
*
Participant Phone
Participant Email
example@example.com
Participant Age Range
*
21-30
31-40
41-50
51 or older
Section 3: Housing Fit
Does the participant have any mobility or accessibility needs?
*
None
Cane
Walker
Wheelchair
First floor room
Other
Is the participant able to live independently without clinical or assisted living support?
*
Yes
No
Unsure
Is the participant ambulatory?
*
Please Select
Yes
No
Unsure
Is the participant able to understand household expectations and make independent decisions?
*
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
Is income stable and 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
*
What is the participant’s expected discharge or move out date?
-
Month
-
Day
Year
Date
Desired Move In Timeframe
*
Immediately
Within 30 days
Within 60 days
Flexible or unknown
Section 4: Additional Information
Is there any additional information or considerations we should be aware of?
Optional: Upload supporting documents
Upload a File
Drag and drop files here
Choose a file
You may upload discharge paperwork or other relevant documents if they are available. Supporting documents are not required to submit this referral.
Cancel
of
Section 5: Confirmation
Confidentially reviewed within one business day.
ONYX GROUP ATLANTA
•
Referral Partner Resources
•
678 337 2209
I confirm that the participant understands this is an independent shared housing program and has agreed to this referral.
*
I Confirm
Submit Referral
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