Wait List Referral Form - Carrfour Supportive Housing

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Wait List Referral Form
Form should be completed by authorized referral source and sent electronically or faxed to:
All Single Adult Programs:
Robin Chambers, or 305-756-2742 (f)
All Family Programs:
Francesca Steele, or 305-513-5176 (f)
*** Incomplete referral forms will be returned.***
Date of Referral
: ___________________________________________
Place of
Relationship
Last 4 Digits
HMIS Number
First Name
Last Name
Gender
D.O.B.
Birth
to HOH
of SSN
(If applicable)
1
HOH
2
3
4
5
6
7
8
1. Applicant’s (HOH) Phone Number: ______________________ Alternate Phone Number: ______________________
2. Applicant’s Email Address: __________________________________________________
3. Employed?
Y
or
N
4. Receiving monetary benefits (SSI/SSDI, TANF, etc.)? Y
or
N
Total Monthly Household Income:$ __________
5. Has applicant been homeless or in shelter 4+ times in the last 3 years?
Y
or
N
6. Is applicant a veteran?
Y
or
N
 Street or other location not meant for human habitation
7. Current Living
 Shelter, Name of Shelter _______________________________________________________
Situation
 Transitional Housing (for homeless persons who originally came from streets or
(Check one)
emergency shelter), Name of Program ___________________________________________
 Other, _____________________________________________________________________
***
HUD funding requires that applicant meet specific living situations in order to be considered eligible for programs.***
8. Does the Head of Household qualify as having a disability that is expected to be of long-continued and indefinite
duration, a developmental disability, or substance abuse, a disease of acquired immunodeficiency syndrome (AIDS) or
.
Y
or
N
conditions arising from the etiologic agency for acquired immunodeficiency syndrome
9. Is the Head of Household receiving (or pending) SSI or SSDI benefits?
Y
or
N
10. Does a child in the household qualify as having a disability that is expected to be of long-continued and indefinite
duration, a developmental disability or a disease of acquired immunodeficiency syndrome (AIDS) or conditions arising from
the etiologic agency for acquired immunodeficiency syndrome
and receiving SSI or SSDI benefits?
Y
or
N
My signature below indicates that the above
information is accurate.
Authorized Referral Signature:
___________________________________________
Print Name:__________________________________
Phone Number:_______________________________
A copy of a business card must be submitted
Email:_______________________________________
with this application.
Date: _______________________________________
Effective Date: 06/2012

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