Angel Haven Independent Living
Referral & Intake Information Form
This form is used to collect preliminary information for referral consideration. Completion of this form does not guarantee placement.
1. Referral Source Information
Name:
Organization (if applicable):
Role/Title:
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Preferred Method of Contact:
Phone
Email
2. Individual Being Referred
Full Name:
Date of Birth / Age:
Gender (optional):
Current Living Situation:
Homeless / Shelter
With Family/Friends
Hospital/Facility
Other
Desired Move-In Timeframe:
Immediate
Within 30 days
30-60 days
Other
3. Level of Independence
Please check all that apply:
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Independent with bathing
Independent with dressing
Independent with toileting
Independent with mobility
Requires reminders or minimal assistance
Additional details (if any):
4. Medical & Behavioral Information
Does the individual have any known medical conditions?
Yes
No
If yes, please list (briefly):
Any behavioral concerns we should be aware of? (Ex: violence, substance abuse, unmanaged mental health concerns)
Yes
No
If yes, please explain:
Is the individual able to self-manage medications?
Yes
No
Requires reminders
5. Financial Information
Primary Source of Income:
SSI
SSDI
VA Benefits
Private Pay
Other:
Monthly Income (approximate):
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6. Housing Preference
Room Preference:
Shared Room ($675/month)
Private Room ($875/month)
7. Additional Information
Please share any additional details that may help us determine appropriate placement:
8. Acknowledgment
I confirm that the information provided above is accurate to the best of my knowledge. I understand that submission of this form does not guarantee placement and that additional information may be required.
Signature (Referral Source):
Date:
-
Month
-
Day
Year
Date
Angel Haven Independent Living
Phone:
Format: (000) 000-0000.
Email:
example@example.com
For office use only
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