LEGACY HOUSING SOLUTIONS ORGANIZATION REFERRAL INTAKE FORM
This referral form is intended for organizations, case managers, workforce coordinators, hospitals, shelters, workforce programs, and community partners requesting temporary workforce or transitional housing placement services through Legacy Housing Solutions.
ORGANIZATION INFORMATION
- Organization Name
- Referral Contact Person
- Referral Contact Phone Number
Format: (000) 000-0000.
- Referral Contact Email Address
example@example.com
- Organization Address
- Department / Program Name
CLIENT / PARTICIPANT INFORMATION
- Client Full Name
First Name
Last Name
- Client Phone Number
Format: (000) 000-0000.
- Client Email Address
example@example.com
- Date of Birth
-
Month
-
Day
Year
Date
- Emergency Contact Name & Phone Number
IDENTIFICATION & VERIFICATION
- Government Issued ID Type
Driver License
State ID
Passport
Other
- Government Issued ID Number
- State of Issue
- ID Expiration Date
-
Month
-
Day
Year
Date
File Upload (Government Issued ID / DL )
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PLACEMENT INFORMATION
- Type of Placement Requested
Emergency Placement
Workforce Housing
Transitional Housing
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Temporary Housing
Shared Accommodation
Requested Move-In Date
Expected Length of Stay
Number of Beds Requested
Is Transportation Assistance Needed?
Yes
No
EMPLOYMENT/INCOME INFORMATION
Is Client Currently Employed?
Yes
No
Employer/Work Location
Shift Schedule
Day Shift
Night Shift
Rotating Shift
Source of Income / Funding
Payment Method
Self Pay
Organization Pay
Voucher
Program Funding
Other
File Upload (Income Verification / Pay Stubs)
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ADDITIONAL INFORMATION
Does the client have any mobility limitations or special accommodation needs?
Additional Notes / Case Information
CERTIFICATION
I certify that the information provided is accurate to the best of my knowledge and that this referral is
being submitted for housing placement consideration.
Referral Contact Signature
Date
-
Month
-
Day
Year
Date
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