Partner Referral

Submit a Referral

For case managers, social workers, hospitals, shelters, reentry programs, veterans organizations, and community partners.

1. Referral Partner Information

Organization Name *Contact Person *Job TitlePhone Number *Email Address *Organization Type *

2. Client Information

Client First Name *Client Last Initial *Age *Gender

3. Current Housing Situation

Select all that apply.

Current Situation

ShelterHospitalTransitional HousingReentry ProgramFamily / FriendsHomelessOwn ResidenceOther

4. Desired Housing

Room Type *

Shared RoomPrivate RoomEither

Move-In Timeline *

ASAPWithin 7 DaysWithin 30 DaysFlexible

5. Funding Source

Select all that apply.

Funding

SSISSDIEmployment IncomeSelf PayVA BenefitsAgency FundingGovernment AssistancePensionOther

Monthly Income (USD, optional)

6. Eligibility Screening

Referral partner must confirm all of the following apply to the client.

Confirm all that apply *

Client is 18 years or olderClient can live independently without 24-hour supervisionClient agrees to a drug-free environmentClient agrees to an alcohol-free environmentClient agrees to a weapon-free environmentClient understands this is shared independent living housingClient is willing to follow house rules

7. Safety & Clinical Screening

Does client require 24-hour supervision? *

YesNo

Does client require skilled nursing care? *

YesNo

Does client require personal care assistance? *

YesNo

Does client require medication administration? *

YesNo

Are there behavioral or safety concerns we should be aware of? *

YesNo

8. Additional Notes

Notes

Before Submitting

Home of a Thousand Hills provides:

• Safe structured housing
• Drug-free environment
• Alcohol-free environment
• Weapon-free environment
• Independent living only (no medical or personal care services)

I certify the information provided is accurate to the best of my knowledge. *

Home of a Thousand Hills

Independent Living Home

Detroit, Michigan Area

info@hoathousing.com