Comfort Commons Housing Professional Referral & Placement Form
Provide referral details and client information so we can review eligibility, availability, restrictions, and safety requirements for potential placement.
Referring Agency & Staff Contact
Referring Agency Name
*
Staff Contact Name
*
First Name
Middle Name
Last Name
Role / Title
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
Please Select
Phone
Email
Text Message
Other
Client Identity & Basic Contact
Client Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Age
Date of Birth
*
-
Month
-
Day
Year
Date
Current Housing Situation & Placement Request
Current housing status
*
Please Select
Unsheltered
Emergency shelter
Transitional housing
Staying with friends or family
Hospital or treatment setting
Correctional facility
Motel or hotel
Own housing, seeking move
Other
Requested move-in date
*
-
Month
-
Day
Year
Date
Urgency level
*
Immediate
Within 7 days
Within 30 days
Flexible
Desired room type
*
Private room
Shared room
Either
Referral reason and placement goals
*
Funding, Employment & Benefit Information
Current Income Sources
*
Employment Wages
Public Assistance
Disability Benefits
Retirement/Pension
Family/Partner Support
Savings
Other
Employment Status
*
Please Select
Employed Full-Time
Employed Part-Time
Unemployed
Self-Employed
Student
Retired
Unable to Work
Other
Benefits Received
Funding / Payment Source Details
*
Support Team & Emergency Contact
Emergency Contact Name
*
First Name
Middle Name
Last Name
Relationship to Client
*
Please Select
Parent
Spouse/Partner
Sibling
Adult Child
Relative
Friend
Neighbor
Case Manager
Support Staff
Other
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Follow-up Contact Method
*
Phone
Text Message
Email
Through Case Manager
Other
Accessibility, Communication & Daily Support Needs
Accessibility needs
Wheelchair access
Accessible bathroom
Visual accessibility support
Hearing accessibility support
No preference
Other
Preferred communication methods
Phone
Text message
Email
In-person
Video call
Other
Daily living support needed
Meal preparation
Medication reminders
Laundry support
None
Other
Transportation needs
Public transit access
Paratransit
Ride assistance
Other
Requested accommodations or additional support details
Behavioral, Safety & Coordination Considerations
Behavioral or support considerations relevant to placement
Anxiety or trauma-related support
Substance use recovery support
History of conflict with roommates or staff
Wandering or elopement risk
Needs structured routine
Other
Safety or placement compatibility concerns
*
Medications or treatment coordination needs
Legal, Reentry & Supervision Information
Release Date
-
Month
-
Day
Year
Date
Registration Requirements
Community supervision
Court registration
Housing restriction
Curfew requirement
Check-in requirement
Other
Special Housing Restrictions
Other Legal or Reentry Constraints
Documents Available
Which documents are available for review?
*
Upload supporting documents (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Consent, Authorization & Certification
Consent to Communicate
*
I consent to communication between Comfort Commons and the referring agency, client, and care team regarding this referral
I consent to sharing relevant information needed for placement review and coordination
I consent to follow-up contact about application status and next steps
Certification of Accuracy
*
I certify that the information provided is true and complete to the best of my knowledge
I understand that incomplete or inaccurate information may delay review or placement
I acknowledge that I am authorized to submit this referral on behalf of the client
Electronic Signature
*
Signature Date
*
-
Month
-
Day
Year
Date
Submit Referral
Submit Referral
Should be Empty: