Luxe Haven's Referral Form Assessment

Luxe Haven's Referral Assessment

We value your input - your answers matter. Please answer as clearly and honestly as possible, as sharing accurate details helps us create the best possible experience for your referral.
Date*

MonthDayYear
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
Relationship to Referral
Client Name*

First NameLast Name
Client Phone Number*
Please enter a valid phone number.
Client Email
Client Current Address*
Do not currently have an address where they reside.
Client Date of Birth*

MonthDayYear
Gender*

FemaleMale
Martial Status*

SingleMarriedSeparatedDivorced
Emergency Contact Name
Emergency Contact Phone Number
Please describe your client's present living situation. How long have they been there?*
If they are in transition, please let us know which of the following best reflects their situation.*

RehabilitationHomelessnessSubstance Abuse RecoveryDomestic Violence ShelterMental Health FacilityRecently IncarceratedSenior Living FacilityEvictionOther
If you answered 'Other', please provide details below:*
If not applicable, please enter 'N/A'.
Are they currently employed?*

YesNo, but I'm seeking employment.No, but I still have a source of income.
Do they have a reliable source of income to cover the program fee, monthly room charges (shared or private), and their personal expenses each month?*

YesNo
What is their source of income?*

SSI/SSDIVA Disability3rd Party Organization PaymentsJob/PaycheckSponsor/Gift/AllowanceOther
If you answered 'Other', please provide details below:*
If not applicable, please enter 'N/A'.
Do they have a secondary source of income?*

YesNo
If 'Yes', please provide details below:*
If not applicable, please enter 'N/A'.
Total Monthly Income Amount*
Are they a veteran?*

YesNo
Which type of room are they applying for?*

Shared RoomPrivate RoomWhichever room is available for immediate move in
How soon are they planning to move?*

ImmediatelyWithin 1-2 weeksWithin 2-4 weeksLater than a month - add me to the waitlist
Will they be the only person participating in the program or will there be someone else accompanying them?*

Yes, they will be the only person.No, someone will accompany them.
Do they have or plan to bring any pet(s) with them?*

YesNo
Do they require any daily assistance with personal care? (i.e. bathing, dressing, medication management, or mobility)*

No, they are completely independent.Yes, they require minimal assistance.Yes, they require complete daily assistance.
If they are prescribed medications, do they take them independently? Please note: Luxe Haven is not a medical facility and cannot administer medication.*

Yes, they take medications independently.Yes, they take their medications but require assistance.No, they do not take any medications.
Do they have any physical limitations or accessibility needs, or require medical supervision or specialized services to live safely day to day?*

YesNo
If 'Yes', please describe:*
If not applicable, please enter 'N/A'.
Can they independently handle daily tasks such as meals, laundry, and cleaning their living space?*

YesNo
This program is designed for independent adults only. It is not an assisted living, group home, or medical housing program. Do you/client acknowledge and understand this requirement?*

YesNo
Are they comfortable living in a shared home community where common areas such as the kitchen, bathroom, living and laundry rooms, are used by other members in the residence?*

YesNo
Are they comfortable sharing a semi-private bedroom with at least one other resident?*

Yes, their just looking for affordable, safe, functional housing.No, they rather pay more to have more privacy.
Have they previously lived in shared housing? If yes, please describe their experience. *
If not applicable, please enter 'N/A'.
Do they agree to follow all program rules, including quiet hours, visitor policies, and cleanliness standards?*

YesNo
Have they ever been asked to leave a residence due to behavior, rule violations, or disturbances?*

YesNo
If 'Yes', please explain:*
If not applicable, please enter 'N/A',
What is your assessment of their character? How do they interact with or handle others? What are some key factors we should be aware of? *
To ensure we place them in the most suitable unit, are they able to safely and comfortably use stairs to reach bedrooms on the second floor?*

YesNo
Have they ever been convicted of a violent crime or property damage? Please note, answering 'Yes' does not automatically disqualify them.*

YesNo
Have they ever been convicted of a sexual offense? Please note, answering 'Yes' does not automatically disqualify them.*

YesNo
Do they have any pending criminal or sexual convictions pending? Please note, answering 'Yes' does not automatically disqualify them.*

YesNo
City and State of conviction(s)*
If not applicable, please enter 'N/A'.
If applicable, provide details of their past or pending convictions.*
If not applicable, please enter 'N/A'.
Our residences are alcohol and drug free (including marijuana). Are they able to comply with this requirement?*

YesNo
Anything Else You'd Like Us to Know?
Feel free to share any additional details that may assist us in offering the best possible support.
Thank you for completing this referral assessment- together, we're building brighter futures, one haven at a time.
Should be Empty:

Luxe Haven's Referral Assessment