S&N Solution Consulting

Referral Application

City *

State *

Clients Name *

Clients Age *

Clients SSN

Phone Number *

Email *

Anticipated Move in Date: *

Anticipated Move out Date:

Housing Type Preference *

Housing Type Preference

Shared Room
Private Room
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Do they need long-term housing? *

YES

NO

How long have they been looking for housing?

Where is client coming from: *

SSI / Alternate Income Amount: *

*All SSI/SSDI are required to have a Representative Payee setup prior to move in*

Medicare or Medicaid: *

Food Stamps Recipient: *

Yes

No

Mental Health/Behaviors: *

Any physical disabilities? *

YES

NO

Medication Currently Taking *

Please state the name of the medication and what it's for

Can they live independently *

YES

NO

If no, what do they need assistance with?

Do they, or will they already have outside services in place? *

YES

NO

With what company?

What are the services?

Can they cook for themselves? *

YES

NO

Can they clean up after themselves? *

YES

NO

Do they have basic housing items? (Toiletries, clothes, etc.) *

YES

NO

Do you have pets? (Negotiable depending on housing requirements.) *

Yes

No

Do they have family? *

YES

NO

(If yes) Name:

Contact Number:

Do they have a social worker/Case Manager? *

YES

NO

(If yes) mention Name:

Alternate Contact Number

Felonies *

YES

NO

Are they required to register as a sex offender in any state? *

Is there any additional information we should know?

Referral Source Information *

Name
Position
Organization