SUPPORTIVE HOUSING PROGRAM

SUPPORTIVE HOUSING PROGRAM
REFERRAL INTAKE FORM
Confidential - For Referral Purposes Only
SECTION 1: REFERRAL SOURCE INFORMATION
Referring Agency / Organization Name
Caseworker / Social Worker Name
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Agency Address
Date of Referral

MonthDayYear
Date
SECTION 2: APPLICANT BASIC INFORMATION
Full Legal Name
Preferred Name (if different)
Date of Birth

MonthDayYear
Date
Age
Gender Identity (Male / Female / Non-Binary / Prefer Not to Say)
Veteran Status (Yes / No)
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Current Living Situation (list all that apply)
SECTION 3: HOUSING NEEDS & TIMELINE
Facing Immediate Housing Loss? (Yes / No)
Requested Move-In Timeline
Preferred Housing Type (Private Room/ Shared Room)

SECTION 4: INCOME & BENEFITS
Currently Has Income? (Yes / No / Pending)
Primary Income Source(s)
Monthly Income Amount
Income Verifiable? (Yes / No / In Process)
Housing Voucher or Subsidy (if any)
SECTION 5: LEVEL OF INDEPENDENCE
ADLs - Describe Level of Independence
Medication Management Level
SECTION 6: MENTAL HEALTH INFORMATION
Mental Health Diagnosis (if any)
Receiving Mental Health Services?
Psychiatric Hospitalization in Past 12 Months?
Emotional Stability in Shared Housing
SECTION 7: MEDICAL & PHYSICAL HEALTH
Chronic Medical Conditions
Mobility Needs / Accommodations
Requires Skilled Nursing Care?
SECTION 8: SUBSTANCE USE (CONFIDENTIAL)
History of Substance Use
Currently Using Substances
Length of Sobriety (if applicable)
Engaged in Treatment or Support Services
SECTION 9: SAFETY & BEHAVIORAL CONSIDERATIONS
History of Violence or Aggression

History of Arson / Sexual Offense / Weapons Charges
Ability to Follow House Rules
Behavioral Concerns Affecting Shared Housing
SECTION 10: LEGAL HISTORY
Current Legal Supervision
Pending Charges or Court Dates
Registered Offender Status
SECTION 11: SUPPORT SYSTEM & SERVICES
Primary Support System
Current Services in Place
SECTION 12: ADDITIONAL INFORMATION
Additional Notes Relevant to Housing Placement
SECTION 13: REFERRAL CERTIFICATION
Referring Staff Signature

Clear
Printed Name
Date

MonthDayYear
Date
PROGRAM NOTICE:
Submission of this referral does not guarantee placement. All referrals are reviewed based on
program capacity, eligibility, safety considerations, and overall fit.
Intake ReviewFollow-Up Call ScheduledWaitlistNot a Fit / Referred Elsewhere
Should be Empty: