Homeless to Housing referral

Date of referral

Client name

Date of birth

Client phone

HMIS ID

Client’s Current Location: (Please include details in comments)*

Shelter

Outside/car/places not meant for human habitation

Other

Does the client know you are making this referal?

Yes

Is the client a veteran?

Yes

How long has the individual been experiencing homelessness?

Does the individual have a known disability?

Referent name

Referent phone number

Referent email address (to receive a copy)

Please confirm referent email address

Referent organization

Referral checklist

Service type	Has	Needs	Comments
Additional MH services (ARMHS, TCM, etc.)
Housing stabilization
Waivered services
Shelter case manager
Other

Resources	Has	Needs	Comments
Income supports/ Employment
Other

Please include any additional needs or details to this referral