Personal Information First Name * Last Name Phone Number * Email * Who is filling out this form today? * Client / Resident Case Manager Hospital Discharge Planner Probation or Parole Officer VSO / Veteran Service Officer Other Professional Eligibility & Pre-Screening Questions Are you (the client) currently homeless or at risk of losing your housing?* * Yes No Why do you (the client) need housing at this time? * How long have you (the client) been displaced or without stable housing? * Do you (the client) have a monthly income or benefits? * Yes No What type(s) of income or benefits do you (the client) currently receive? SSI (Supplemental Security Income) SSDI (Social Security Disability Insurance) Social Security Retirement VA Disability Benefits VA Pension Housing Voucher or Subsidy Other If “Other,” please describe your income type * Do you (the client) have any pending legal issues, probation, or parole supervision? * Yes No Are you (the client) currently working with a case manager or support agency? Yes No Do you (the client) have any immediate safety concerns or medical needs? * Yes No How often are you (the client) hospitalized or receiving medical/mental health treatment? What are your (the client) long-term goals? * Where were you (the client) living before (for references)? * Has another home, shelter, or program completed an assessment on you (the client)? * Yes No Not Sure Eligibility & Pre-Screening Questions Client Date of Birth * Current Housing Situation * Main Barriers or Challenges * Client’s Immediate Needs * Reason for Referral * Additional Notes (Optional) Professional Referral Section Your Name (Professional) Last Name (Professional) Agency / Organization Name Your Phone Number (Professional) Your Email (Professional) Client ID / Case Number Upload Any Supporting Documents (Optional Maximum file size: 5 MB Professional Referral Section Consent to Submit * I confirm that the information provided is accurate and I have permission to submit this referral. Date Signed * Submit Referral
