Homeless Services Referral Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Referring Agency
Referring Worker
Referrer's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referrer's Email
example@example.com
Is the individual currently experiencing literal homelessness and searching for housing?
*
Yes
No
Is the individual a Dane County Resident?
*
Yes
No
Is this individual searching for housing with children?
Yes
No
Which of the following best describes the individuals current living situation?
*
Place not meant for human habitation
Emergency shelter, including hotel paid for w/ emergency shelter voucher
Foster care home or foster care group home
Jail, prison or juvenile detention facility
Psychiatric hospital or other psychiatric facility
Hospital or other residential non-psychiatric medical facility
Substance abuse treatment facility or detox center
Long-term care facility or nursing home
Hotel paid for w/o emergency shelter voucher
Rental by client, no ongoing housing subsidy
Residential project w/ no homeless criteria
Staying or living w/ family or friends
Client doesn’t know
Permanent housing for formerly homeless persons
Rental by client, w/ ongoing housing subsidy
Transitional housing for homeless persons
Owned by client, no ongoing housing subsidy
If in an institution or hospital, where was the individual sleeping the night before entry?
If exiting an institution or hospital, where will the client be sleeping while searching for housing?
Is this individual currently working with any other case managers?
Does this individual have a disability that is verifiable by a licensed clinician?
Yes
No
Does this individual identify as having a mental health diagnosis and/or substance abuse disorder?
Yes
No
Other Helpful Information or Notes?
Submit
Should be Empty: