Alta Lux Living - Referral Form
Please use this form to refer an individual or family who is in need of secure and affordable housing assistance.A staff member will review the referral and follow up within 24–48 hours.If you have questions, contact info@altaluxliving.com or call 826-203-1040. Thank you for your referral.
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Client Information
Full Name
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Prefer not to say
Phone Number
*
Email Address
Preferred method of communication?
Text
Phone
Email
Current Living Situation
Please Select
Homeless
Hospital
Transitional Housing
Staying with Family/Friends
Other
If homeless, how long ?
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Employment & Income
Employment Status
*
Please Select
Employed
Unemployed
On Assistance
Retired
Other
Income Source (SSDI, SSI, voucher, etc..)
*
Monthly Income $
*
Funding Agency (If applicable)
Will the agency assist with payment?
Yes
No
Required Income Verification Documents (submit one): Most recent pay stub (within last 30 days) SSI/SSDI award letter (current year) Unemployment benefits statement Pension or retirement income statement Bank statement (last 30 days) showing recurring income deposits Benefit Verification
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Support Assessment & Background Information
Are you Fully Independent
Yes
No
Do you have any allergies?
*
Yes
No
If yes, please list:
Do you have any medical conditions we should be aware of
*
Yes
No
If yes, please explain:
Are you currently taking any medication?
*
Yes
No
If yes, please list:
If yes, can you manage independently?
*
Yes
No
Is there any history of violence or aggressive behavior within the last 12 months?
*
Yes
No
Do you currently use tobacco or nicotine products (cigarettes, cigar, vaping, etc) ?
*
Yes
No
Are there any current concerns related to substance use (alcohol or drug misuse)?
*
Yes
No
If yes, please explain:
Are you willing to comply with our zero-tolerance policy regarding alcohol, illegal drugs, and substance misuse?
*
Yes
No
Any convictions or legal issues?
*
Yes
No
If yes, please explain
Are you currently on probation or parole?
Yes
No
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Referring Agency Information
Agency Name
*
Referrer's Name
Your Relationship to the Person/Family Being Referred
Family Member
Friend/Acquaintance
Social Worker/Case Manager
Healthcare Provider
Other
Referrer's Contact Email
*
Referrer's Contact Phone Number
*
Additional case notes or relevant information
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Housing Preferences
Preferred Bedroom
Private Room
Shared Room
No preference
Comfortable with a shared living environment?
Yes
No
How soon do you need housing?
Pets?
Yes
No
To help maintain a safe and respectful living environment, are you willing to follow house rules, including maintaining a drug and alcohol free environment, no weapons, observing quiet hours, and cleanliness expectations?
*
Yes
No
Do you acknowledge that common areas may be monitored by security cameras for safety purposes?
Yes
No
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Confirmation & Authorization
*
I understand that Alta Lux Living is a supportive independent living program and does not provide medical or clinical services.
*
I certify that the information provided in this referral form is true and accurate to the best of my knowledge
Submit
Should be Empty: