L.P.M.H. Housing Referral Form
Residential & Sober Living
APPLICANT INFORMATION
Full 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 Address
*
example@example.com
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have any medical or mental health concerns you would like us to be aware of?
*
Yes
No
If yes, please list your health concern.
EMERGENCY CONTACT
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
HOUSING INFORMATION
Are you seeking housing for yourself?
*
Yes
No
If no, who are you seeking housing for?
Desired Move-In Date?
*
How did you hear about L.P.M.H.?
*
Treatment Center
Probation/Parole
Family/Friend
Online Search
Social Media
Community Agency
CURRENT SITUATION
Current Living Situation
*
Homeless
With Family/Friends
Shelter
Hospital or Treatment Center
Other
RECOVERY INFORMATION
Are you currently in recovery?
*
Yes
No
Length of Sobriety (if applicable):
*
Less than 30 days
30-60 Days
3-6 Months
6-12 Months
1 Year or More
Not Applicable
Are you willing to follow house rules and maintain a drug/alcohol-free environment?
*
Yes
No
FINANCIAL INFORMATION
How will housing fees be paid?
*
Self-Pay
Employment Income
Disability Income (SSI/SSDI)
Veterans Benefits
Reentry Program Assistance
Community Agency Assistance
Other
Currently Monthly Income (if any):
*
No Income
Less than $500
$500-$1000
$1001- $2000
$2001-$3000
Over $3000
Do you anticipate being able to pay housing fees on time each month?
*
Yes
No
Unsure
Are you requestion financial assistance, sponsorship, or scholarship consideration?
*
Yes
No
if yes, please explain your financial need:
REFERRAL INFORMATION
Are you being referred by an agency, case manager, probation officer, or treatment provider?
*
Yes
No
Agency/Organization
Referring Party Name
*
First Name
Last Name
Referring Party Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Party Email
*
example@example.com
I certify that the information provided on this form is true and accurate to the best of my knowledge.
*
Yes
No
Please type your name. This will act as a legal signature upon submission of this form.
*
Additional Notes or Comments
Submit Referral
Should be Empty: