Client Referral Form

Client Referral Form

Complete this referral form with the requested information.
Referral Info
Referrer Name

First NameMiddle NameLast Name
Organization
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Client Details
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender

Other
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Emergency Contact Address
Do you have a valid photo ID?
Upload Photo ID

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If required, are you able to provide a copy of your Birth Certificate?
Are you able to provide a copy of your social security card?
Last 4 digits of SSN
Housing
Currently Housed
Have you ever been removed or asked to leave somewhere you were living?
Name of Person, Program or Organization
Address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Point of Contact
Estimated Move-In Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
What Is Your Preferred Location?
Room Preference
What type of housing is your preferred choice?
Do you own a pet or service animal?
Do you agree to abide by a zero-tolerance policy regarding illegal drugs, unprescribed substances, alcohol, and weapons on the property?
Are You Willing To Relocate To Any Area Other Than Preferred Location?
Do You Smoke or Vape?
Income
Income Source

Other
If other, specify income source.
Monthly Income Amount
Proof of Income

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Fee Responsibility
If Self-Pay is not selected, please provide the name, address, email address, and phone number of the person or organization responsible for the fee.
Enter all applicable contact details in one response.
Health & Legal
What are your primary transportation needs? (Select all that apply)
Do you currently receive home health care services?
Home Health Provider / Company Name
If this does not apply, enter N/A.
Provider Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Would you like assistance exploring eligibility and applying for home health care services?
Mobility Devices Needed?
Accommodations / Support Needed

Other
Do you currently receive or require support for any mental or behavioral health conditions?
Do you take any prescribed medications?
Formally Diagnosed Health & Behavioral Conditions
If this does not apply, enter N/A.
Diagnostic Verification
Treatment Plan & Expected Prognosis
If this does not apply, enter N/A.
Medical and health history details are collected strictly to assess residential placement requirements and necessary support accommodations. Information provided is kept confidential and processed in accordance with applicable privacy regulations.
If taking medications, are you compliant in taking prescribed medications?
Do you have any known allergies.
List Known Allergies
If this does not apply, enter N/A.
Are there any substance use or recovery considerations that would help us select the most supportive living environment for you?
Additional information to be taken into consideration
If this does not apply, enter N/A.
Do you have any charges pending against you?
Charges Details
If this does not apply, enter N/A.
Are you on probation or parole?
Date of Completion

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
List Offenses
Are you subject to any state or federal offender registry requirements?
Offense Registration Details
If this does not apply, enter N/A.
Additional Information
Is there any other information that needs to be disclosed?
If this does not apply, enter N/A.
Independent Living Readiness Screening
Are you able to manage all daily personal care tasks (bathing, dressing, grooming, eating) independently without hands-on assistance?
Are you able to store, track, and take your prescribed medications independently and on schedule?
Are you able to identify household safety hazards, call emergency services (911) if needed, and evacuate the building unassisted in an emergency?
Are you capable of preparing simple meals, doing light cleaning and laundry, and maintaining a clean, sanitary living space?
Are you able to live respectfully with roommates, abide by shared house rules, and ensure your monthly housing expenses or program fees are paid on time?
If you answered "No" to any of the questions above, please specify what assistance, accommodations, or external care providers you use to manage that task:
If this does not apply, enter N/A.
Authorization & Signature

Authorization for Release of Information I authorize the release, exchange, and disclosure of verbal, written, and electronic information, including but not limited to personal identifiers, housing history, income, background information, support needs, and any other information reasonably necessary to evaluate my eligibility and assist in securing housing. This authorization is granted to housing providers, case managers, property managers, service agencies, and any other person or organization deemed necessary to complete the housing evaluation and placement process. This authorization shall remain in effect for one (1) year from the date of signature unless revoked earlier by me in writing.
I agree to the Release of Information terms
E-Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How did you hear about LovnCos Resource Services, LLC?

Other
Should be Empty:

Client Referral Form

Referral Info

Client Details

Housing

Income

Health & Legal

Additional Information

Independent Living Readiness Screening

Authorization & Signature