Partner Referral Form

This form is intended for use by case managers, social workers, discharge planners, probation and parole officers, and partner organizations submitting referrals on behalf of a client seeking housing placement.
Submission of this form does not guarantee placement, approval, or availability. All housing decisions are based on current availability and standard occupancy criteria.

Bloom House Living provides housing only and does not offer medical care, supervision, treatment, or case management services. We may assist occupants with connecting to community-based resources and provide a community resource handbook upon move-in.
All occupants must demonstrate the ability to live independently and are responsible for managing their own care, appointments, and services. Placement is governed by a License to Occupy Agreement and does not create a landlord-tenant relationship.

By submitting this form, you confirm that you are an authorized referral partner and that all information provided is accurate to the best of your knowledge.

Agency / Organization Name

Case Manager Full Name

First NameLast Name

Case Manager Email

example@example.com

Case Manager Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Title / Role

Preferred Contact Method

Is this time-sensitive?

Urgency

Referral Source

Discharge/Release Date if applicable

Date

Client Current City - (Please Select Closest Area)

Desired Placement Area

Any location restrictions or transportation concerns?

Support Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship

Support Contact Email

example@example.com

May JDE contact this person regarding placement coordination?

Is this person involved in financial decisions/payment?

Is this person involved in ongoing support?

Client Full Name

First NameLast Name

Client Phone number

Please enter a valid phone number.Format: (000) 000-0000.

Client Sex

Monthly Income

Is third-party funding currently approved?

If yes, funding agency/program

Approximate monthly amount available for the occupancy fee

Would the client like information about a Housing Contribution Review?

Client Date of Birth

Date

Is there a support person we may contact?

Support Contact

First NameLast Name

Current Housing Situation

Room Preference?

Move In Timeline

Expected Length of Stay

Income Sources(s)

Client Monthly Income

Does the client need help exploring additional benefits and resources?

Background Level

Basic Functional / Scope Screen

Rows	Yes	No	Unsure
Can the client live independently or semi- independent?
Can client understand and follow house expectiations and safety instructions
Can client move around the home safely using their mobility device, if any?
Self-Administer Meds
Eat without hands on assistance?
Can perform ADLs independently or thorugh and outside third party provider?
Does client Require Nursing Care?
Does Client require medication adminstraton ?
Does Client require continouse supervision or 24/7 staff?
Is an outside caregiver/provider currenlty involved?

Are there any safety or behavioral considerations the placement team should be aware of?

Is the client comfortable with a shared living environment?

Is the client able to meet standard house expectations such as cleanliness and respecting property rules?

Are there any mobility, accessibility, or accommodation needs?

Who currently supports the client ?

How often is reliable support available?

How involved will family/ support remain after placement?

Type a question

Please upload H&P and Face sheet

Additional Notes or Context

I confirm that all information provided is accurate and that I am an authorized to submit this referral.

Date

JDE Housing Solutions — Partner Referral & Triage

Referring Agency Information

SECTION 2 — Client Information

SECTION 3 — Housing Needs

SECTION 4 — Income & Funding

SECTION 5 — Special Considerations

SECTION 6 — Existing Support

SECTION 7 — Likely Support + Resource Needs

SECTION 8 — Documents & Notes

SECTION 7 — Confirmation