CASEWORKERS REFERRALS

Thank you for referring to the Merging Hearts Independent Living Program. Please complete all sections below. Upon receipt, our team will review the referral and contact you within 2-3 business days.

Submission of this form does not guarantee acceptance into the program. All referrals are subject to review and approval based on program criteria. Merging Hearts reserves the right to deny any referral that does not meet program criteria.

Referring Caseworker / Agency Information

Caseworker / Contact Name

Title / Position

Agency / Organization Name

Phone Number

Email Address

Fax Number

Client Information

Client Full Name

Date of Birth

Phone Number

Current Living Situation

Client Eligibility Confirmation (Required for Placement Consideration)

Client Eligibility Confirmation

Client is able to live independently without supervision

Client does not require medical or clinical care

Client is able to manage their own medications

Client is able to perform daily living tasks (bathing, cooking, hygiene, etc.)

Client is not actively using drugs or alcohol

Client understands this is a shared living environment

Client has no behaviors that would pose a risk to others in a shared environment

Does the client have a disability?

Yes

No

If yes, please describe:

Does the client require a handicap accessible living environment?

Yes

No

Does the client have a mental illness or mental health diagnosis?

Yes

No

If yes, please describe:

Does the client need help recovering from opioids, drugs, or alcohol?

Yes

No

Is the client currently enrolled in a recovery or treatment program?

Yes

No

If yes, program name:

Is the client a registered sex offender?

Yes

No

If yes:

Restriction within 1,000 feet of schools, parks, or designated areas

No 1,000 foot restriction

Will the client have children living with them as a participant?

Yes

No

If yes, list number of children and ages

Does the client have pet or animal?

Yes

No

If yes:

Service Animal

Emotional Support Animal

Pet

Please disclose any relevant information that may impact placement:

History of behavioral concerns

History of substance use

Any safety concerns for shared living:

Criminal background

Incomplete or inaccurate information may result in denial or removal from the program.

Room Type Requested:

Room Type Requested

Shared Room ($750+)

Shared Room/Private Bath ($900+)

No Preference

Requested Move-In Date

What is the expected length of stay?

1 month

3 months

6 months

Longterm

Is the client able to consistently meet monthly program fees?

Yes

No

How will program fees be paid?

Self-Pay

SSI/SSDI

Agency Payment

Other

If agency-supported, provide payment details/contact:

Referral Details

Reason for Referral & Client Needs (Include housing need, stability concerns, and any relevant background)

Additional Notes

By signing below, I confirm that the information provided is accurate to the best of my knowledge and that the client has been informed of the nature of the Merging Hearts program. I understand that submission of this referral does not guarantee placement, and all applicants are subject to program review and approval.

Caseworker Name

Agency / Organization

Caseworker Signature

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Date

Month

Day

Year