Harmony Hearts Case Manager Referral Form

This form is to be completed by a referring caseworker or agency representative to request placement consideration for a program participant. Submission does not guarantee approval or placement.

IMPORTANT NOTICE:Harmony Hearts is paid shared housing, not free or emergency housing. Children cannot reside in the facility. All locations are strictly drug and alcohol-free. A background check is required for all applicants. Individuals with sexual or violent crime convictions are ineligible for placement.

First Name

Last Name

Caseworker Email

Caseworker Phone Number

Job Title / Role

First Name

Last Name

Participant Date of Birth

Gender

Participant Phone Number

Current Living Situation

Referral Reason

Desired Move-in Timeframe

Mobility Needs

Is the participant able to manage activities of daily living independently?

Yes

No (Requires assistance)

Home Health Services

Mental Health & Medical Conditions

Current Alcohol/Drug Use or Recovery Status

Legal Background (Felony, Violent Offense, Probation/Parole, Sex-Offender Registration Status)

Participant Income Sources

SSI / SSDI

Employment

Pension / Retirement

Government Assistance (TANF, General Relief)

No Income

Other

Approximate Monthly Income ($)

Verified Source & Amount Paying for Housing

Will the participant receive ongoing case management from your agency?

Yes

I certify that the information provided in this referral is accurate to the best of my knowledge. I understand that submitting this form does not guarantee placement, and I authorize Harmony Hearts to contact me regarding this referral.