Residential Referral Form
Please complete this form to refer an individual for supportive independent living with Restored Life Homes.
Referral Source Information
Referring Person's Name
*
First Name
Last Name
Referral Source Email
*
example@example.com
Referral Source Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization/ Agency
*
Job Title/ Role
Referral Setting
Inpatient Psychiatric Hospital
Medical Hospital
Community Mental Health Agency
Case Management Agency
Court/ Justice Program
Shelter/ Homeless Services
Residential Treatment Program
Family/ Self- Referral
Other
Individual Being Referred
Individual Being Referred Name
First Name
Last Name
DOB
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current Location/ Placement
Example: Huntsville Hospital, Downtown Rescue Mission Family Residence
Current Living Situation
*
Hospital/Inpatient Facility
Shelter
Family/ Friends
Currently Unhoused
Residential Faciltiy
Independent Housing
Other
When Is Housing Needed?
*
Immediately
Within 7 days
Within 30 days
Future Placement
Unknown
Expected Discharge Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Housing and Financial Information
Preferred Room Type
Shared Room
Private Room
Either
Primary Source of Income
*
SSI
SSDI
Employment
Retirement/Pension
Family Support
Other
No Current Income
Unknown
Approximate Monthly Income
Enter approx. Monthly Income
Representative Payee?
Yes
No
Unknown
Representative Payee Name/ Organization
Representative Payee Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How Will The Monthly Program Fee Be Paid?
Individual/Self Pay
Representative Payee
Family/ Other Responsible Party
Agency/Program Funding
Other
Unknown
Independent Living Screening
Can The Individual Independently complete Basic ADLs, Including Bathing, Dressings, Toileting, Eating, and Basic Personal Needs?
*
Yes, Independently
Yes, with Occasional Reminders/Prompts
Requires Hands-on Assistance
Unknown
Can the Individual Independently Manage Their Medications
*
Yes, Independently
Needs Reminders/ Prompts
Requires Medication Administration/Assistance
No Current Medications
Unknown
Can the Individual Safely Remain in the Home Without 24-Hour Supervision?
*
Yes
No
Unknown
Does the Individual Have Any Mobility or Accessibility Needs?
No
Yes
Unknown
Please Describe Any Mobility or Accessibility Needs:
Behavioral & Safety Information
Within the past 90 days, has the individual experienced any of the following? (Select all that apply)
*
Physical Aggression Towards Others
Serious Threats Towards Others
Significant Property Destruction
Elopement or Wandering Concerns
Fire-Setting Behavior
Recent Psychiatric Hospitalization
Other Significant Safety Concerns
None known
If Any Selected Above, Please Briefly Describe The Circumstances and Current Status
Does The Individual Have Any Current Legal Or Court Involvement That May Affect Housing Program Participation?
No
Yes
Unknown
Please Briefly Describe Any Legal/Court Involvement.
Current Services & Supports
Is The Individual Currently Connected With Any of The Following Services?
Case Management
Psychiatry/ Medication Management
Therapy/Counseling
ACT Team
Primary Care
Substance Use Treatment
Vocational/ Employment Services
Probation/ Parole or Court Program
None
Unknown
Current Provider(s) / Agency Information
Please List the agency/provider name and contact information, if known.
Referral Information
Please Briefly Describe The Reason For The Referral and Why Supportive Independent Living is Being Requested.
*
Is The Individual Aware That This Referral Is Being Submitted?
Yes
No
Unknown
May Restored Life Homes Contact The Individual Directly Regarding This Referral?
*
Yes
No
Please contact the referral source first
Submit
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