LEGACY HAVEN PRIME
Agency Referral Form
Referring Agency Information:
Agency/Organization Name
Referring Caseworker/Staff Name:
Title/Role:
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Contact Method:
Phone
Email
Text
Applicant Full Name:
Date of birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email (if available)
example@example.com
Current location:
Hospital
Shelter
Street/Unsheltered
Living with family/friends
Hotel/Motel
Transitional Program
Other
Is the applicant a Veteran:
Yes
No
Unknown
Is the applicant service connected?
Yes
No
Unknown
Funding and Payment Source
What funding source will be used for housing? (Select all that apply)
SSVF
HUD-VASH
Hospital stabilization funds
Community housing funds
SSI/SSDI
Employment income
Payee/Rep payee
Other
Is funding already approved?
Yes
Pending
Not yet started
Can your agency verify and confirm funding if needed?
Yes
No
Support Services
Is the applicant currently working with your agency?
Yes
No
Type of support provided:
Case Management
Mental health services
Medical/Clinical services
Housing support
Disability services
Other
Will the applicant continue receiving your support after placement?
Yes
No
Housing Needs & Stability
Requested Move-in date:*
-
Month
-
Day
Year
Date
Preferred room type:
Shared
Private
Either
Does the applicant require a downstairs bedroom?
Yes
No
Does the applicant have mobility limitations?
Yes
No
Does the applicant have any behaviors that could affect shared housing?
No
Yes
If yes, explain:
Has the applicant been violant or aggressive in the past 12 months?
No
Yes
If yes, must include Caseworkers notes:
Income and Documentation
Select all that apply
Does the applicant have: (Select all that apply)
Valid ID
SS Card
Proof of income
Caseworker verification letter
Emergency contact
None of the above
Additional Notes and Safety Information
Is the applicant currently medica stable for community living?
Yes
No
Is the applicant able to manage medication independently?
Yes
No
Any concerns we should be aware of?
Referral Certification
"I confirm that the information provided is accurate to the best of my knowledge"
Referring Staff Signature (e-signature OK)
Today's Date:
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: