Open Path Living- Referral Form
Thank you for considering Open Path Living. This form is intended for case managers, social workers, community professionals, family members, and others assisting an individual with locating independent shared housing. Please complete the information below, and a member of our team will contact you regarding availability and next steps. Need assistance before submitting a referral? Call Open Path Living Group at 804-243-6667 or Email Info@openpathliving.com.
Open Path Living -Title and Introduction
Please note: Submission of this form does not guarantee placement or housing availability.
Name*
First Name
Last Name
Organization/Agency*
Your Role*
Phone Number*
Please enter a valid phone number.
Format: (000) 000-0000.
Email*
example@example.com
Preferred Method Of Contact*
Please Select
Phone
Email
Prospective Resident Information
Prospective Resident's Name*
First Name
Last Name
Phone Number*
Please enter a valid phone number.
Format: (000) 000-0000.
Email*
example@example.com
Date Of Birth*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current City/ Locality*
How Soon Is Housing Needed?
Please Select
Immediately
Within 7 Days
Within 30 Days
Flexible
Desired Move-In Date*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Housing Needs
This section is important for determining whether you may have an appropriate opening.
What is the individual's current housing situation? Examples: Living with family/friends, Temporary Housing, Shelter, Currently Housed, other.
Does the prospective resident have a reliable source of funds for monthly housing costs?
What is the anticipated source of housing payment? Examples: Employment income, SSI/SSDI, retirement, housing assistance, family support, other
Open Path Living provides independent shared housing and does not provide skilled nursing, assisted living, or continuous hands-on personal care services. Is the prospective resident seeking an independent shared-housing environment?*
Please Select
Yes
No
Unsure
Does the prospective resident require services that Open Path Living does not provide as part of the housing arrangement?
Please Select
Yes
No
Unsure
Please briefly describe the housing-related service being requested: (Optional text box.)
Is there anything else you would like us to know about the individual's housing needs or referral?
How did you hear about Open Path Living Group?
Referral Acknowledgment* I understand that submitting this referral does not guarantee admission or placement and that Open Path Living will review the referral and contact me regarding next steps and availability.
I Agree
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Submit Referral
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