Veterans Balanced Solutions (VBS) Referral Form Packet
Agency-focused referral and intake documentation for non-clinical shared housing. Complete all sections to refer a client and provide required consent and notices.
Referring Agency / Partner Information
Please provide your agency details so we can contact you if needed.
Agency Name
*
Agency Contact Person (Full Name)
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client (Referred Individual) Information
Enter the details of the person being referred for shared housing.
Client Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Contact Method
*
Phone
Email
Other
Client Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client Email Address
example@example.com
Current Living Situation
*
Please Select
Homeless
Temporary Housing
With Family/Friends
Shelter
Other
Referral Details
Provide information about the referral and specific needs.
Reason for Referral
*
Does the client require reasonable accommodation?
*
Yes
No
Unsure
Please describe any reasonable accommodation needs (if applicable)
Additional Notes (optional)
Fair Housing Notice
Fair Housing and Equal Opportunity Notice: Veterans Balanced Solutions LLC (VBS) abides by all federal, state, and local fair housing laws. We do not discriminate based on race, color, national origin, religion, sex, familial status, disability, or other protected classes. If you require a reasonable accommodation, please indicate above.
Consent to Exchange Information
Client authorization is required to share information for placement screening.
Consent to Exchange Information: By signing below, I authorize Veterans Balanced Solutions LLC (VBS) and its partners to exchange information as necessary for housing placement screening and coordination. I understand this consent is voluntary and may be revoked at any time in writing.
Client Signature (Required for Consent)
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit Referral
Submit Referral
Should be Empty: