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
Does the resident currently receive any form of income or benefits?
Primary source of monthly income
Estimated monthly income amount (USD)
How will housing payments be made?
Does the resident have a representative payee?
If yes, name of payee
Are funds available for security deposit and first month's payment?
If a third party will assist with payment, provide name and contact information
SECTION 3 – Cognitive & Independent Living Screening
Can the resident understand and follow basic house rules?
Is the resident able to manage personal hygiene independently?
Is the resident oriented to the current date or month?
Does the resident manage medications independently?
Does the resident require reminders or supervision for daily tasks?
SECTION 4 – Mobility & Physical Ability
Can the resident walk independently without assistance?
Does the resident use a mobility aid?
Can the resident independently get in and out of bed and use restroom facilities?
SECTION 5 – Housing Background
Current living situation
Reason for seeking housing
Has the resident ever been asked to leave or removed from a residence?
If yes, please explain
SECTION 6 – Safety & Behavioral Screening
Has the resident ever displayed violent behavior toward others?
Has the resident ever been arrested or charged with a violent offense?
Has the resident been removed from housing or shelter due to behavioral issues?
If yes, explain
Does the resident have a history of aggressive behavior or altercations?
Are there behavioral concerns that could affect safety of other residents?
SECTION 7 – Substance Use Verification
Does the resident currently use alcohol?
Does the resident currently use illegal drugs or misuse prescription medications?
Is the resident enrolled in a drug or alcohol rehabilitation program?
SECTION 8 – Level of Care Verification
Does the resident require assistance with bathing, dressing, toileting, medication administration, nursing care, or memory care supervision?
Can the resident safely live independently without daily supervision?
SECTION 9 – Applicant Acknowledgment
Is the resident receiving home health or nursing services?
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