Supportive Housing Referral Form
Complete this referral form for supportive housing. Please answer all required fields and provide accurate contact, housing, health, income, and consent information.
Intake & Contact Information
Intake Date
*
-
Month
-
Day
Year
Date
Referral Agency / Referrer Name(Referral Code)
Participant Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Last 4 Digits of Social Security Number
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Gender
*
Male
Female
Non-binary
Prefer not to say
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Housing Situation & Referral Details
Current Living Situation
*
Homeless
Couchsurfing/Staying with others
Transitional Housing
Jail/Prison Release
Hospital/Rehab
Other
Current Living Situation - Other
Referral Source
*
Self
Agency
Parole/Probation
Hospital or Treatment Center
Family/Friend
Referral Source - Agency Name
Referring Contact Name
First Name
Middle Name
Last Name
Brief Summary of Situation / Reason for Housing Need
*
Health, Behavioral Health, and Legal History
Medical & Mental Health History
*
Mental Health Diagnosis & Medication History
*
Substance Use History
*
Alcohol
Drugs
None
If yes, please explain
Are you currently on parole or probation?
*
Yes
No
Parole/Probation Officer Name and Phone Number
Are you a registered sex offender?
*
Yes
No
Income, Accommodations, and Housing Preferences
Do you have a source of income?
*
Yes
No
Income Source
*
SSI
SSDI
Employment
Other
Income Source - Other
Monthly Income Amount
*
Any disabilities or accommodations needed?
*
Yes
No
Disabilities or accommodations - If yes, explain
Can you live independently and manage your Activities of Daily Living (ADLs) without assistance?
*
Yes
No
If no, please explain
Do you currently have or need a home health care provider or outside support service?
*
Yes
No
Home health care / outside support service - Agency Name
Participant and Staff Attestation
Participant Initials
Participant Initials - Date
-
Month
-
Day
Year
Date
Participant Name
*
First Name
Middle Name
Last Name
Participant Signature
Participant Signature - Date
-
Month
-
Day
Year
Date
Staff Name
Staff Signature
Staff Signature - Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: