SUBMIT A REFERRAL
Thank you for your referral. This form is for professionals and community partners referring prospective residents to Align Housing Solutions. Please complete the information below so we can determine whether our supportive housing program is the right fit.
REFERRAL PARTNER INFORMATION
Organization Name:
*
Referral Contact Name:
*
First Name
Last Name
Job Title:
*
Phone Number:
*
-
Area Code
Phone Number
Email Address:
*
How long have you worked with the client you're referring?
*
PROSPECTIVE RESIDENT INFORMATION
Name
*
First Name
Last Name
Phone Number:
*
-
Area Code
Phone Number
Email:
example@example.com
Current City:
*
Preferred Contact Method
*
Phone
Text
Email
HOUSING NEEDS:
Has the prospective resident been informed of this referral?
*
Yes
No
Has the prospective resident consented to be contacted by Align Housing Solutions?
*
Yes
No
Current Housing Situation
*
Homeless
Emergency Shelter
Transitional Housing
Staying with Family/Friends
Renting
Other
Desired Move-In Timeframe
*
Immediate (0–7 Days)
Within 30 Days
Within 60 Days
Within 90 Days
Flexible
ELIGIBILITY SNAPSHOT
Is the prospective resident able to live independently?
*
Yes
No
Is the prospective resident a veteran?
*
Yes
No
What branch did he/she serve in?
*
Air Force
Coast Guard
Navy
Army
United States Marine Corps
Space Force
Does the prospective resident currently receive supportive services from outside providers?
*
Yes
No
Which services does the prospective resident currently receive? (Select all that apply)
*
Case Management
Home Health
Physical Therapy
Occupational Therapy
Veteran Services
Disability Support Services
Other
Primary Source of Income:
*
Employment
VA Disability
Social Security
Pension
Program Assistance
Other
Unknown
Estimated Monthly Income (If Known)
*
Under $1,000
$1,000–$1,999
$2,000–$2,999
$3,000+
Unknown
ADDITIONAL INFORMATION
Please provide any additional information that may help us determine whether Align Housing Solutions is an appropriate fit for the prospective resident.
Submit Referral
Should be Empty: