United by Purpose Referral Form

REFERRAL PARTNER INFORMATION & FORMS
This packet contains referral requirements, eligibility standards, and referral forms for partner organizations.

SECTION 1: PROGRAM OVERVIEW
About United by Purpose Independent Living
United by Purpose Independent Living is a structured, non-clinical transitional housing program for adults who are able to live independently and are transitioning from homelessness or housing instability.
The program provides a stable housing environment while participants work toward long-term independence, self-sufficiency, and housing stability. UUnited by Purpose operates with clear expectations, accountability, and collaboration with referral partners.
Program Model
- Independent living housing (non-clinical)
- Structured rules and expectations
- Regular check-ins and accountability
- Focus on housing stability and self-sufficiency
- Referral-based placement only
What This Program IS
- Transitional housing
- Independent living environment
- Supportive but non-clinical
- Structured accountability
- Referral-based placement
What This Program IS NOT
- Emergency shelter
- Medical facility
- Mental health treatment center
- Detox or inpatient program
- 24-hour supervised housing

SECTION 3: REFERRAL PROCESS
All referrals must follow the process outlined below to ensure
appropriate placement and program fit.
- Referral partner reviews eligibility criteria
- Referral forms are completed and submitted
- Pre-admission screening is conducted
- Acceptance, waitlist, or denial decision issued
- Approved clients complete full intake prior to move-in

SECTION 4: REQUIRED REFERRAL FORMS
The following forms must be submitted for referral consideration:
- Referral Cover Sheet
- Referral Intake Summary
- Pre-Admission Eligibility Screening
- Release of Information (ROI), if applicable
Incomplete submissions may delay processing.

REFERRAL COVER SHEET
Form UBP-IL-100
Referral Information
Referring Organization
Department / Program
Referral Contact Name
Referral Contact Phone
Referral Contact Email
example@example.com
Client Information
Client Name
Client Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
Urgency Level (check one)
RoutineTime SensitiveDischarge Pending
Authorization
I certify that the information provided is accurate to the best of my knowledge.
Requested Move-In Timeframe
Referral Authorization Signature

Clear
Date (MM/DD/YYYY)

MonthDayYear
Date
CONFIDENTIALITY NOTICE
This document contains confidential information intended solely for referral and housing placement purposes. Unauthorized disclosure is prohibited.

RELEASE OF INFORMATION (ROI) - PARTNER USE
Form UBP-IL-400
I authorize United by Purpose Independent Living to communicate with the referring organization listed above regarding my referral, eligibility, and program participation.
Client Name
Client Signature

Clear
Date (MM/DD/YYYY)

MonthDayYear
Date
Should be Empty:

SECTION 4: REQUIRED REFERRAL FORMS