Resident Referral Form

Client Intake & Placement Request

Referral Source Information

Agency / Organization Name:

Referring Staff Name:

Title/Role:

Phone Number:

Email *

Preferred Contact Method:

Phone

Text

Email

Date Of Referral

Client Information

Full Name

Date of Birth:

Phone *

Email (if applicable)

Emergency Contact:

Name
Relationship
Phone

Income & Funding

Monthly Income Amount:

Payee Involved:

Yes

No

If yes, Payee:

Name
Contact

Housing Needs & Preferences

Preferred Move‑In Date:

Preferred Location(s):

Type of Housing Needed:

Room in Shared Home

Private Unit

Accessible Unit

No Preference

Mobility Needs:

None

First‑floor required

Wheelchair accessible

Other:

Gender Preference for Household (if any):

Any pets or service animals:

Yes

No

If yes, describe:

Support Needs & Background

Does the client have a case manager or support worker:

Yes

No

If yes:

Name
Contact

History of Evictions

Yes
No
Unknown

Background Considerations:

None

Non‑violent history

Other (describe):

Any safety concerns the homeowner should be aware of:

Current Situation

Reason for Referral:

Urgency Level:

Emergency (needs placement within 24–72 hours)

High Priority (within 1–2 weeks)

Standard (within 30 days)

Additional Notes

Behavioral considerations:

Communication style:

Daily living support needs:

Other important information:

Referral Source Acknowledgment

I confirm that the information provided is accurate to the best of my knowledge and that

the client is aware of this referral.

Referring Staff Signature:

Clear

Date

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