• Miles Independent Living Supportive Housing Program

    Miles Independent Living Supportive Housing Program

    Referral Form

  • Referral Party Information

    Thanks for your interest in Miles Independent Living. This form takes about 5 minutes and helps us understand next steps. Please complete all required fields to be considered for placement. If you are referring someone else, answer to the best of your knowledge.
  • Format: (000) 000-0000.
  • Preferred Method of Contact*

  • Participant Information

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Age Group*
  • US Citizenship?*
  • Gender*
  • Background*
  • Current Living Situation*
  • Income Source*
  • VA Benefits?*
  • DD-214 on File?*
  • Does the Participant have documentation for income verification?*
  • Can Participant live independently and manage your Activities of Daily Living (ADLs) without assistance?*

  • *Your signature below indicates that the information you have provided above is truthful to the best of your knowledge.  Incomplete applications may delay review.  A member of our team will contact you within 2 business days.

     

    Confidentiality: Your responses are kept confidential and used only to determine eligibility and placement.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: