AGENCY REFERRAL REQUEST
For Referring Agencies & Community Organizations
This form is intended for agency or organizational referrals only. Submission does not guarantee acceptance or placement. All referrals are reviewed for eligibility, program fit, safety, support needs, documentation, and current availability.
1. REFERRING AGENCY / ORGANIZATION
Agency / Organization Name:
Agency Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Agency Phone:
Format: (000) 000-0000.
Agency Email:
example@example.com
Referring Professional Name:
First Name
Last Name
Title / Position:
Direct Phone:
Format: (000) 000-0000.
Direct Email:
example@example.com
Preferred Method of Contact:
Phone
Email
2. INDIVIDUAL BEING REFERRED
Full Legal Name:
First Name
Last Name
Preferred Name (if different):
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Phone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Current Address / Current Living Situation:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the individual aware this referral is being submitted?
Yes
No
Best way to contact the individual:
Phone
Email
Through Referring Agency
3. SERVICE / PLACEMENT REQUESTED
Program requested (select one):
Long-Term Membership
30-90 Day Emergency Placement
Room preference:
Shared Membership
Private Membership
Either / Based on Availability
Requested / Anticipated Start Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Urgency:
Routine
Time-Sensitive
Immediate Need (subject to availability; not emergency shelter)
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4. REASON FOR REFERRAL & CURRENT CIRCUMSTANCES
Primary reason for referral:
Housing instability
Life transition
Reentry
Aging / senior support
Aging out of foster care (18+)
Domestic violence survivor
Veteran
Other
Please briefly describe the individual's current circumstances and why this referral is being made:
5. SUPPORT NEEDS & PROGRAM FIT
Known support needs or barriers (check all that apply):
Transportation
Employment
Benefits
Housing resources
Community resources
Veteran resources
Reentry support
Senior resources
Transition planning
Other
Does the individual require nursing, custodial, clinical, 24-hour protective oversight, or a level of care beyond an independent/shared-living setting?
No
Yes
Unknown
If yes or unknown, please explain:
Known accommodation needs:
None known
Yes
Unknown
If yes, please describe:
Known safety concerns or information relevant to placement/program fit:
6. INCOME / PAYMENT INFORMATION
Known income / benefit source(s):
Employment
SSI
SSDI
Veteran benefits
Unknown
Other
Who is expected to be financially responsible?
Individual
Referring Agency
Other Third Party
To Be Determined
If agency / third party may be responsible, is written payment authorization available?
Yes
No
Pending
N/A
The Queendom Reserve does not assume that an agency, benefit program, grant, insurer, or other third party will pay. Applicable rates, payer responsibility, authorization, invoicing, and payment terms must be confirmed before service delivery when payment is required.
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7. CURRENT SERVICES / TRANSITION INFORMATION
Current Case Manager / Support Professional (if different):
First Name
Last Name
Agency / Organization:
Phone / Email:
Current services or community providers involved:
For 30-90 Day Placement referrals: anticipated transition / next-step plan, if known:
8. DOCUMENTS / INFORMATION AVAILABLE
Documents / Information Available Checklist
Photo ID / identity information
Income / benefit documentation
Emergency contact information
Medication list (informational only)
Relevant discharge / transition information
Payment authorization
Other supporting documents
None currently available
Other:
9. AGENCY ACKNOWLEDGMENT & SIGNATURE
By signing below, I confirm that I am submitting this referral in my professional capacity on behalf of the agency or organization identified above and that, to the best of my knowledge, the information provided is accurate. I understand that this referral is a request for review only and does not guarantee acceptance, membership, room type, placement, availability, or funding. I understand that The Queendom Reserve is a non-clinical independent/shared-living support program and is not an emergency shelter, hospital, nursing facility, or emergency response service.
Referring Professional Printed Name:
First Name
Last Name
Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Agency / Organization:
THE QUEENDOM RESERVE - OFFICE USE ONLY
Date Received:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewed By:
First Name
Last Name
Referral Status:
Pending Review
Additional Information Needed
Approved
Not Approved / Not a Fit
Program:
Long-Term Membership
30-90 Day Placement
Room Type (if applicable):
Shared
Private
TBD / Based on Availability
Notes / Follow-Up:
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Should be Empty: