Oak House Resident Referral Form
Help connect someone with safe, structured transitional housing. Completion of this referral form does not guarantee admission. All referrals are reviewed individually.
Referral Source Information
Please tell us about yourself so we know who is making this referral and how to contact you if additional information is needed.
Use the information below to tell us about the referral source and the person completing this form.
Who is being referred?
*
Please Select
Cedar Residence – Adult Men's Transitional Housing
Acorn Residence – Adult Women's Transitional Housing
Harbor Residence – Family Crisis Housing
What best describes your relationship to the individual being referred?
*
Please Select
Self Referral
Family Member
Friend
Hospital
Social Worker / Case Manager
Mental Health Provider
Substance Use Treatment Provider
Probation / Parole
Law Enforcement
School
Church / Faith Organization
Community Agency
Employer
Other
Referring person's full name
*
First Name
Middle Name
Last Name
Organization (if applicable)
Job Title (if applicable)
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
May Oak House contact you if additional information is needed regarding this referral?
*
Yes
No
Email
example@example.com
Please provide as much information as you know about the individual being referred. If you do not know an answer, you may leave optional fields blank.
Preferred contact method
*
Phone
Email
Text Message
Person Being Referred
Full Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
-
Month
-
Day
Year
Date
Does the individual know they are being referred to Oak House?
*
Yes
No
Unsure
Has the individual already completed an Oak House Program Application?
Yes
No
Unsure
Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current City
*
Current County
Emergency Contact (if known)
First Name
Middle Name
Last Name
Referral Details
Please provide any information that will help Oak House understand the individual's current situation and determine whether our program may be an appropriate fit.
Why are you referring this individual to Oak House?
*
What strengths, supports, or positive qualities do you believe will help this individual succeed?
Is there anything else you would like the Oak House Admissions Team to know about this referral?
Current concerns (select all that apply)
Housing instability
Homelessness
Domestic violence
Recovery support
Mental health support
Employment
Financial hardship
Family crisis
Recently incarcerated
Medical concerns
Transportation
Other
Contact Permission
This information helps Oak House determine how and when we may appropriately contact the individual being referred.
Do you know if this individual is aware of this referral?
*
Yes
No
Unsure
Has the individual given Oak House permission to contact them?
*
Yes
No
Unsure
If Oak House is able to contact the individual, what is the best way to reach them? (Please include any helpful instructions, preferred contact method, best time to call, or alternate contact information.)
Would you like an Oak House team member to follow up with you regarding this referral?
Yes
No
Is there anything specific you would like to discuss with our Admissions Team?
Acknowledgment
Acknowledgments
*
I certify the information provided is true to the best of my knowledge.
I understand this referral does not guarantee admission.
I understand Oak House may contact the individual if permission has been provided or when otherwise appropriate and permitted.
Electronic Signature
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit Resident Referral
Confirmation
How urgent is this housing need?
*
Immediate (within 24–48 hours)
Within 1 week
Within 30 days
Planning ahead / Not urgent
Unsure
Is the individual currently working with another agency, case manager, or service provider?
Yes
No
Unsure
Agency / Organization Name (optional)
Oak House may be limited in our ability to contact the individual directly without their knowledge or permission. If appropriate, our Admissions Team may contact you for additional information or discuss the next steps.
Submit Resident Referral
Submit Resident Referral
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