Referral

Applicant Information
Last Name*: First Name*:
DOB*: Age*:
Phone Number*:
(xxx-xxx-xxxx)
Alternative Number:
(xxx-xxx-xxxx)

Referral Source
Referral Agency*: Phone Number*:
(xxx-xxx-xxxx)
Person Referring*: Ext.:
Referrers Email*:
Present Living Situation of applicant*: Homeless Shelter Transitional Prison Streets Other
Explain other:

Resource/Assistance Information
Is the applicant receiving or eligible for funding or aid? (SSI, SSDI, TCA, TDAP or Ryan White)* Yes No
Does applicant have a history of alcohol or substance abuse?* Yes No

Mental Health
Does applicant have a mental health diagnosis?* Yes No If yes, please list:
Has applicant ever been convicted?* Yes No If yes, please list:
Is applicant a sex offender?* Yes No *Required fields
Program fees are as follows:
  • •$75 deposit-must be paid to reserve your spot in the program
  • •$125 weekly
Clicking submit confirms that the client assumes responsibilty for program fees listed above.