Referral Intake Form — Safe Ground Housing

1

Referring Agency

Information about the agency or individual making this referral

Agency / Organization *

Case Manager Name *

Case Manager Phone *

Case Manager Email *

2

Basic details about the individual being referred

Client Full Name *

Date of Birth *

Gender (optional)

Client Phone (if available)

Current Location / Address (optional)

3

Client's current housing status and history

Current Housing Status *

How long without stable housing *

Primary reason for instability *

4

Helps us assess fit and prepare appropriate support

Currently employed? *

Yes No Part-time

Source of income (if any)

Sober / Drug & Alcohol-Free? *

Yes No In recovery

Criminal background? *

Yes No

Please briefly describe

Medical or mental health needs (optional)

5

Help us understand why this client is a good fit

Why is this client a good fit for Safe Ground Housing? *

Any urgent circumstances?

Preferred move-in timeframe *