Veterans Balanced Solutions LLC Self-Referral Packet

Veterans Balanced Solutions LLC Self-Referral Packet

Submit your self-referral for non-clinical shared housing. This form collects referral details, obtains consent, and documents fair-housing notices.
Veteran's Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Are you currently experiencing homelessness?
Reason for Referral / Housing Needs
Do you have any specific accommodation needs or requests?
Do you have a history of service in the U.S. Armed Forces?
Branch of Service
Fair Housing and Reasonable Accommodation Notice: Veterans Balanced Solutions LLC operates in compliance with all applicable fair housing laws. If you require reasonable accommodations due to a disability, please indicate above or contact us for assistance.
Consent to Exchange Information: By signing below, I authorize Veterans Balanced Solutions LLC to share my information with relevant agencies for the purpose of placement screening and housing support. I understand that my information will be handled confidentially and only for the purposes stated above.
Signature (Consent to Exchange Information)
If you are submitting this packet as a completed file, please upload it here.

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