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.

Referral Source

Client Full Name

First NameLast Name

Client Phone number

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

Client Sex

Client Date of Birth

Date

Client Current City - (Please Select Closest Area)

Type of Housing Preferred?

Move In Timeline

Current Housing Situation

Expected Assignment Duration?

Income Sources(s)

Client Monthly Income

Monthly Budget

Background Level

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?

Upload any supporting documents

Additional Notes or Context

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

Date

Partner Referral Form

Referring Agency Information

SECTION 2 — Client Information

SECTION 3 — Housing Needs

SECTION 4 — Income & Funding

SECTION 5 — Special Considerations

SECTION 6 — Documents & Notes

SECTION 7 — Confirmation