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Refer a Resident

First name*

Last name*

Email*

Phone

Date of Birth*

Month

Day

Year

Address*

Emergency contact name*

Emergency contact phone*

Current living situation*

Homeless

Shelter

With Family/Friend

Transitional Home

Other

If other, please explain

Able to manage daily routine?*

Yes

No

If no, please explain

Able to maintain clean living space?*

Yes

No

Okay with shared living?*

Yes

No

Able to safely cook & prepare own meals?*

Yes

No

Taking prescribed medications?*

Yes

No

Can take medications independently?*

Yes

No

N/A

Medical conditions?*

Yes

No

If yes, please explain

Receiving mental health support?*

Yes

No

Substance use? (select all that apply)*

Alcohol

Marijuana

Nicotine/Tobacco

Other

None

If other, please explain

Willing to live in drug/alcohol/smoke free home?*

Yes

No

History of violent/abusive behavior?*

Yes

No

If yes, please explain*

Able to follow curfew? (unless approved)*

Yes

No

Agree to No Visitors/Overnight Guests?*

Yes

No

Agree to participate in chores/home upkeep?*

Yes

No

Agree to meetings & check ins?*

Yes

No

Agree to follow house rules?*

Yes

No

Open to staff feedback?*

Yes

No

Agree to no pets?*

Yes

No

Short term goals*

Long term goals*

Steady income?*

Yes

No

Income source (check all that apply)*

Employment

SSI/SSDI

V.A. Benefits

Program assistance

Other

If other, please explain

Monthly income amount*

Upload income verification (pay stub, benefit approval letter, etc)*

Able to afford program fee?*

Yes

No

Not Sure

Financial obligations (child support etc)*

Yes

No

If yes, please explain*

Secure ID Upload ( government issued ID)

Previous Landlord name*

Previous Landlord contact (phone or email)*

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