Pre-Eligibility Referral Form

Pre-Eligibility Referral Form

Please complete this pre-eligibility screening to help us assess your initial eligibility for our housing program.
Application Date

MonthDayYear
Date
When does the client need to be placed?

MonthDayYear
Date
Applicant Information

Provide your personal details below.
Full Legal 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
Gender Identity (This helps with placement only)
Race
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Are you currently working with a Repersentive or Case Manager?
Agency Name, Email and Phone Numder (if applicable)
Repersentive's Organazation (VA, DHS, etc)
Current Housing Status (select all that apply)

Other
Reason for Seeking Housing
Does the client need the following services
Are you currently employed?
Employer Name
How long have you been employed? (if applicable)
Other Income Sources (select all that apply)
How much does the client recieves monthly (approximate)
Total Monthly Income (all sources)
Supportive Service Needs (if applicable, select all that apply)

Other
Have you ever been evicted?
If yes, please explain eviction history briefly
Are you currently on probation or parole?
Do you have any pending legal issues?
Has the client be convicted of a felony?
If yes, please explain pending legal issues briefly
Does the client suffer from mental illness?
If yes, enter mental diagnosis
Does the client currently or in the past had an substance abuse issues?
Do you have any medical conditions that require accommodation?
If so, please share
Is the client disabled?
If yes, please explain your medical condition(s) requiring accommodation
Are you able to live independently with minimal supervision?
Program Understanding and Acknowledgment

Please read the following before signing.
I understand that:
• This is a pre-eligibility screening, not a guarantee of housing.
• Acceptance is based on eligibility, availability, and program requirements.
• Background checks and income verification may be required.
• Participation in supportive services may be required (if applicable).
Applicant Signature
Signature Date

MonthDayYear
Date
Should be Empty:

Pre-Eligibility Referral Form

Applicant Information

Program Understanding and Acknowledgment