Northwest Indiana Structured Living Initiative
Agency Referral Form
Referring Agency Information
Agency Name:
Agency Address:
Agency Phone:
Format: (000) 000-0000.
Case Manager/Referral Coordinator:
Email Address:
example@example.com
Date of Referral:
-
Month
-
Day
Year
Date
Applicant Information
Full Name:
Date of Birth:
-
Month
-
Day
Year
Date
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Current Address:
Referral Category
Referral Category
Veteran
Senior (55+)
Former Foster Youth
Reentry
Homeless
At Risk of Homelessness
SSI/SSDI Recipient
Employed
Student
Current Housing Situation
Current Housing Situation
Homeless
Emergency Shelter
Staying with Family/Friends
Transitional Housing
Correctional Facility
Treatment Facility
Rental Housing
Other
Income Information
Monthly Income:
Income Source
Employment
SSI
SSDI
Veteran Benefits
TANF
Pension
Other
Support Needs
Support Needs
Housing Stabilization
Independent Living Skills
Employment Assistance
Education Assistance
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Budgeting Assistance
Transportation Assistance
Healthcare Referrals Mental Health Resources
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Next
Referral Summary
Required Documents
Government Photo ID
Proof of Income
Benefit Award Letter
Referral Letter
Discharge Paperwork
Case Plan
Agency Certification
I certify that the information provided is accurate and the applicant consented to this referral.
Case Manager Signature:
Date:
-
Month
-
Day
Year
Date
Office Use Only
Date Received:
-
Month
-
Day
Year
Date
Intake Scheduled:
Approved:
Yes
No
Waitlist:
Yes
No
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