REFERRAL | Haven's Way Independent Living

Referring Party Information:

First Name

Last Name

Your Organization Name

Your Role/Title

Full Name

Phone Number

Date of Birth

Gender

Current Location

Is the client aware of this referral?

Is this client currently under supervision?

Does the client have any history of violent or sexual offense? If yes, please briefly explain:

Any pending legal charges?

Diagnosed mental health condition? If yes, is there a current treatment plan?

Substance use history:

Currently sober? If yes, how long:

Is the client open to a structured shared living environment?

Income Source:

Monthly Income Estimate:

Preferred Move in Date

Is your client willing to share a room?

Any additional notes or concerns?

Today's Date:

I confirm that the information provided is accurate to the best of my knowledge and the client has consented to this referral.