Resident Referral & Eligibility Assessment

Resident Referral & Eligibility Assessment

Please complete this assessment to help us determine eligibility for Magnolia Heritage Home Solutions’ Independent Housing Program. All information is confidential and used only for eligibility review.
SECTION 1 – Resident Information
Resident's Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Resident*
Who is completing this form?*
SECTION 2 – Financial & Benefits Verification
YesNo
Primary source of monthly income*
Estimated monthly income amount (USD)*
How will housing payments be made?*
YesNo
If yes, name of payee
YesNo
If a third party will assist with payment, provide name and contact information
SECTION 3 – Cognitive & Independent Living Screening
YesNo
YesNo
YesNo
YesNo
YesNo
SECTION 4 – Mobility & Physical Ability
YesNo
Does the resident use a mobility aid?*
YesNo
SECTION 5 – Housing Background
Current living situation*
Reason for seeking housing*
YesNo
If yes, please explain
SECTION 6 – Safety & Behavioral Screening
YesNo
YesNo
YesNo
If yes, explain
YesNo
YesNo
SECTION 7 – Substance Use Verification
YesNo
YesNo
YesNo
SECTION 8 – Level of Care Verification
YesNo
YesNo
SECTION 9 – Applicant Acknowledgment
YesNo
Select how you were referred below: Type option 1 Local OrganizationType option Caregiver 2 Type Option 3 Family Social Worker
If yes, describe the services
Applicant Name*
Relationship to Resident*
Date*

MonthDayYear
Date
Email
example@example.com
Emergency Contact Name*
Should be Empty:

Resident Referral & Eligibility Assessment

SECTION 1 – Resident Information

SECTION 2 – Financial & Benefits Verification

SECTION 3 – Cognitive & Independent Living Screening

SECTION 4 – Mobility & Physical Ability

SECTION 5 – Housing Background

SECTION 6 – Safety & Behavioral Screening

SECTION 7 – Substance Use Verification

SECTION 8 – Level of Care Verification

SECTION 9 – Applicant Acknowledgment