1. Organization / Facility Name
*
Referring Organization
2. Referring Staff Name
*
Referrer Name
3. Referring Staff Phone
*
Referrer Phone
4. Referring Staff Email
Referrer Email
5. Client Full Name
*
Clients Full Name
7. Client Date of Birth
*
Clients DOB
9. Requested Room Type
*
Shared room
Private room
Either
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Room Preference
10. Where is the client currently staying?
*
Hospital
Detox
Treatment Program
Shelter
With family/friends
Living independently
Homeless / on the street
Other
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Client Current Location
11. Expected discharge or move date
Client Discharge Date
12. What is the client's sobriety status?
*
Yes
No
In treatment now
Recently completed treatment
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Sober Status
13. Is the client willing to live in a sober, drug-free home?
*
Yes
No
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Sober Home Agreement
14. Income Source (if known)
Employment
SSI/SSDI
Family/Support
Unemployment
No income
Unknown
Other
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Income Source (Optional)
15. Legal Requirements
Legal Requirements (Optional)
16. Safety Concerns
Safety Concerns (Optional)
17. Case Manager Notes
Referrer Notes (optional)
18. Best way to reach client
*
Phone Call
Text Message
Email
Case Manager Only
Other
Type an Option
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Client Contact Method
19. Does the client need immediate housing (within 24–72 hours)?
*
Yes
No
Not Sure
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Client Immediate Need
20. Attach supporting documents (optional)
Examples: ID, discharge plan, summary, notes
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