Client Referral Form
Refer a client for independent living housing (MIL HoLm). Please complete all required sections to determine eligibility.
Referring Party Information
Please provide your contact and organization details.
Referring Organization Name
*
Referrer Full Name
*
First Name
Last Name
Title / Role
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Method of Contact
*
Phone
Email
Referred Individual Information
Provide details about the individual being referred.
Client Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Non-binary
Prefer not to say
Other
Current Living Situation
*
Shelter
Transitional Housing
Hospital / Facility
With Family/Friends
Other
Current City & State
*
Independent Living Eligibility
These questions determine eligibility for MIL HoLm. All are required.
Can the client independently complete activities of daily living (bathing, dressing, toileting, feeding)?
*
Yes
No
Does the client require hands-on personal care or 24-hour supervision?
*
Yes
No
Does the client require medication administration or medical care?
*
Yes
No
Income & Funding Source
Please provide information regarding income and funding.
Primary Income Source
*
Please Select
SSI
SSDI
VA Benefits
Employment
Other
Monthly Income Amount (if applicable)
Housing Assistance or Subsidy (if applicable)
Background & Stability Questions
Please answer the following questions about the client's background and stability.
History of evictions in the past 3 years?
*
Yes
No
History of violent behavior?
*
Yes
No
Open to shared housing?
*
Yes
No
Able to follow house rules and community expectations?
*
Yes
No
Additional Notes
Provide any relevant background or transition details.
Relevant background or transition details
Requested move-in timeframe
Acknowledgment & Certification
Please read and certify the following statements.
Submit Referral
Should be Empty: