Referral Partner Housing Interest Form
Parkway Grove Shared Living provides furnished shared housing for adults seeking stable, independent living in a respectful, drug and alcohol-free home environment. Residents have private bedrooms and share common spaces such as the kitchen, bathroom, and living areas. This form is intended for professionals and organizations submitting housing referrals for individuals who are able to live independently without clinical supervision or assisted living support. Submission of this form allows our team to review housing fit and does not guarantee immediate placement.
Referral Source Section
Please provide your information below
Your Name:
*
First Name
Last Name
Organization Name:
Your role or title:
*
Your Phone Number:
*
-
Area Code
Phone Number
Your E-mail:
*
example@example.com
Particiapant Information
Please enter the person's info that is in need of housing.
Full Name:
First Name
Last Name
Phone Number:
-
Area Code
Phone Number
E-mail (Optional):
example@example.com
Date of Birth or Age: (Must be 50 years and over)
Current living situation
*
Living with family/friends
Shelter
Transistional Housing
Hotel
Shared Housing
Currently without stable housing
Other
Housing Needs
Is the individual able to live independently safely w/o supervision?
*
Yes
No
Unsure
Is the individual able to move independently?
*
Yes
No
Unsure
Is the individual comfortable living in a shared home environment with other residents and shared common spaces (kitchen, bathroom, living areas)?
*
Yes
No
Unsure
To your knowledge, does the individual demonstrate behavior that would allow them to live respectfully with roommates?
*
Yes
No
Unsure
Does the individual have stable reoccurring income?
*
Yes
No
Unsure
Primary income source:
*
Employment income
SSI / SSDI
Self-employed
Retirement income
Disability income
Organization assistance
Unsure
Desired move-in timeframe:
*
Immediate
Within 30 days
Within 60 days
Flexible
Additional Information
Notes or considerations:
I confirm this referral is appropriate for independent shared living housing. By providing my contact information, I consent to communication regarding this referral.
*
I agree
Other
Would you like to be notified when rooms become available?
*
Yes
No
Signature
*
Continue
Continue
Should be Empty: