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
MaleFemale
Race
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship*
YesNo
Agency Name, Email and Phone Numder (if applicable)
Repersentive's Organazation (VA, DHS, etc)
Currently HomelessLiving with Family/FriendsTransitional HousingShelterRenting (lease ending soon)Other
Reason for Seeking Housing*
Apply for SSI/SSDIApply for SNAP bennefitsApply for vetern benefitsApply for Medicaid or Medicare
YesNo
Employer Name
How long have you been employed? (if applicable)
SSI/SSDIVA BenefitsGuardian PaymentsThird-Party PaymentsGovernment Assistance ProgramsPay Check
How much does the client recieves monthly (approximate)
Total Monthly Income (all sources)
Light Case ManagementDaily Living & Stability SupportEmployment & Education SupportTransportation AssistanceResource & Life-Skills SupportOther
YesNo
If yes, please explain eviction history briefly
YesNo
YesNo
YesNo
If yes, please explain pending legal issues briefly
YesNo
If yes, enter mental diagnosis
YesNo
YesNo
If so, please share
YesNo
If yes, please explain your medical condition(s) requiring accommodation
YesNo
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