Structured Housing Referral Form
Thank you for referring an individual to our structured housing program. Please complete the information below to help our team review the referral and determine whether our program may be an appropriate fit.
Referring Professional Information
Referral Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Agency / Organization
*
Case Manager / Referral Contact Name
*
Title / Role
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Individual Being Referred
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Living Situation
*
Please Select
Homeless/Unsheltered
Shelter
Transitional Housing
Staying with Family/Friends
Other
Current Support Needs
Requires assistance with Activities of Daily Living (ADLs)?
*
Yes
No
Unknown
Describe the ADL assistance needed
Has current medical support needs?
*
Yes
No
Unknown
Describe the current medical support needs
Behavioral Health & Substance Use Information
Are there any behavioral health needs or concerns?
*
Yes
No
Unknown
Additional behavioral health information
Is there a history of substance use concerns?
*
Yes
No
Unknown
Is the individual currently in recovery or receiving substance use support?
*
Yes
No
Unknown
Additional substance use information
Financial Information
Current income source
Employment
SSI/SSDI
Disability Benefits
Retirement
No Current Income
Other
Estimated monthly income
Safety Considerations
Are there any safety concerns or important considerations?
*
Yes
No
Please explain the safety concerns or important considerations
Program Fit Information
Is the individual aware of this referral?
*
Yes
No
Unknown
Is the individual interested in participating in a structured housing environment?
*
Yes
No
Unknown
Current services or supports involved
Case Management
Behavioral Health Services
Substance Use Recovery Services
Medical Services
Employment Services
Other
Referring Professional Certification
Referring Professional Name
*
Agency/Organization
*
Date Submitted
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Certification
*
I certify the information provided above.
Preferred Contact Method
Phone
Email
Text
In-person
Submit Referral
Should be Empty: