Shozanio's Place Safe Housing Referral Application
Collect referral details, participant information, eligibility responses, screening information, and consent for direct contact. Submission does not guarantee placement; all referrals are subject to pre-screening, eligibility review, bed availability, and program requirements.
Referral Partner Information
Organization Name
*
Referring Staff Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Participant Information
Participant First Name
*
Participant Last Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Participant Identification/Documentation Status
Has ID
No ID
In process/unknown
Age Group
*
18–24
25–34
35–44
45–54
55+
Participant Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Eligibility Questions
Is the participant female?
*
Yes
No
Current status
*
Currently incarcerated
Released
If released, how long ago?
Less than 30 days
1–6 months
6–12 months
More than 12 months
Is the participant currently on probation, parole, or community supervision?
*
Yes
No
Does the participant currently have safe and stable housing?
*
Yes
No
Program Screening
Is the participant willing to follow house rules and program requirements?
*
Yes
No
Unsure
Is the participant actively seeking employment, training, or self-sufficiency services?
*
Yes
No
Does the participant have any special accommodation needs?
*
Yes
No
If yes, please describe the special accommodation needs.
Priority Assessment
What is the participant's current housing situation?
*
Homeless
Staying with Family/Friends
Shelter
Transitional Housing
Correctional Facility
Other
Why is the referral being made today?
*
Consent to Share Referral Information
*
Yes
No
Participant Preferred Contact Method
Phone
Email
Text
May Shozanio's Place contact the participant directly?
Yes
No
Any Safety or Risk Concerns for Placement
Yes
No
Unsure
Submit
Submit
Should be Empty: