Clone of Shared Housing Referral Intake/Waitlist Form

Shared Housing Referral Form

Thank you for your interest in Resilient Residence. We prioritize referrals for clients who are ready to live respectfully in a shared setting and follow program guidelines. We’re excited to work with you. Please fill out this form, and our team will reach out when housing becomes available.
Referrer Full Name

First NameLast Name
Referrer Job Title
Referrer Email Address
example@example.com
Referrer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referrer Organization (e.g., United Way, VA, etc.)
Client's Full Name

First NameLast Name
Client Email Address
example@example.com
Client's Birthdate

MonthDayYear
Date
Client Gender

Other
Client's Phone Number (if applicable):
Please enter a valid phone number.Format: (000) 000-0000.
Do we have permission to text/leave a message on the number(s) provided?
Client's Current Living Situation
What type of room does the client prefer?
Does the client need a semi-private shared room?
When does client need to be placed?
How will the client pay?
How much income does the client receive monthly? If none, please type NONE
Is income consistent?
Is client able to live independently?
Is the client able to live respectfully with others in a shared space?
Any history of violent behavior?
Is the client able to follow house rules and shared living expectations?
Brief Client Overview
Please give us a brief summary about the client. Share relevant housing needs, support level, current situation, and anything helpful for placement review.
Select all of the services client is requesting.

Other
Is client currently working with a case manager?
Will your organization provide ongoing support?
How did you hear about us?
I understand this is a structured shared living program.
I understand placement is based on availability and approval.
Thank you for your referral. A member of our team will follow up as soon as possible regarding next steps and availability.
Should be Empty:

Shared Housing Referral Form