GLT Homes
Thank you for partnering with GLT Homes. Please complete this referral form to submit a client for housing consideration. A member of our team will review the referral and contact you regarding the next steps.
Case Manager or Referral Contact Name
First Name
Last Name
Agency Name
Agency Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Agency Email Address
example@example.com
Client Full Name
First Name
Last Name
Client Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client Date of Birth
-
Month
-
Day
Year
Date
Current Housing Situation
Please Select
Homeless
Shelter
Transitional Housing
Staying with Friends/Family
Renting
Other
Monthly Income
Please Select
Employment
SSI
SSDI
Veterans Benefits
Retirement
Other
Desired Move-In Date
-
Month
-
Day
Year
Date
Does the client have any mobility needs, disabilities, or special accommodations?
Additional Notes
Client Emergency Contact
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
I certify that I am authorized to make this referral and that the information provided is accurate.
Yes
Submit Referral
Should be Empty: