30-90 DAY EMERGENCY PLACEMENT APPLICATION
Thank you for your interest in The Queendom Reserve. This application is for our short-term 30-90 day emergency placement add-on service for single adults. It helps us understand the immediate housing need, referral information, support needs, and transition planning. Submission does not guarantee placement; applicants must meet current eligibility and availability requirements.
1. APPLICANT INFORMATION
Full Legal Name
First Name
Last Name
Preferred Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Current Address / Current Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
First Name
Last Name
Relationship
Emergency Contact Phone
Format: (000) 000-0000.
2. APPLICATION / REFERRAL INFORMATION
Who is completing this application?
Applicant / Self
Referral Agency / Partner
Other
Referral Agency / Organization (if applicable)
Referral Contact Name
First Name
Last Name
Referral Contact Phone / Email
3. EMERGENCY PLACEMENT REQUEST
Requested placement period
30 Days
60 Days
90 Days
Other / To Be Determined
Requested Move-In Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Living Situation
Reason Emergency Placement Is Needed
Deadline to Leave Current Location (if any)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
4. BASIC ELIGIBILITY & SUPPORT NEEDS
Applicant is a single adult age 18 or older
Yes
No
Can applicant live in a non-clinical independent/shared housing environment?
Yes
No
Needs Review
Accessibility / Accommodation Needs
Transportation Needs
Other Important Support Information
SUPPORT • STABILITY • OPPORTUNITY • COMMUNITY
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30-90 DAY EMERGENCY PLACEMENT APPLICATION
5. INCOME, BENEFITS & PAYMENT INFORMATION
Responsible payer
Self
Referral Agency
Third Party
To Be Determined
Income / Benefit Source(s)
Approx. Monthly Income
Agency Billing Contact (if applicable)
Payment Authorization / Arrangement
6. HOUSE RULES & PLACEMENT EXPECTATIONS
If approved, the member must review and follow The Queendom Reserve house rules and safety expectations, respect the home and other members, comply with visitor and conduct requirements, participate in required check-ins, and work toward the agreed transition plan. House rules and the placement agreement will be reviewed before or at move-in.
7. TRANSITION PLAN AFTER 30-90 DAYS
This placement is temporary. Transition planning begins during the placement rather than waiting until the final day. The Queendom Reserve may use its resource program to help identify appropriate next-step housing or community resources. When an agency made the referral, we will coordinate with the agency and member regarding the discharge plan. A member is not automatically returned to the referring agency unless that is the agreed plan. Possible next steps may include long-term housing, another housing provider, an agency-arranged placement, or another appropriate independent living arrangement. Extensions are not guaranteed and depend on eligibility, availability, and written approval.
Known / Preferred Next Housing Option
Case Manager / Transition Contact
Transition Support Requested
ACKNOWLEDGMENT & SIGNATURE
I certify that the information provided is true and complete to the best of my knowledge. I understand that submission does not guarantee acceptance or placement and that additional review, documentation, eligibility requirements, availability, and payment arrangements may apply.
Applicant / Member Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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