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
Race (select all that apply)*
Client Eligibility Confirmation (Required for Placement Consideration)
Client Eligibility Confirmation*
Does the client have a disability?*
Does the client require a handicap accessible living environment?*
Does the client have a mental illness or mental health diagnosis?*
Does the client need help recovering from opioids, drugs, or alcohol?*
Is the client currently enrolled in a recovery or treatment program?*
Is the client a registered sex offender?*
Will the client have children living with them as a participant?*
Does the client have pet or animal?*
Please disclose any relevant information that may impact placement:
Incomplete or inaccurate information may result in denial or removal from the program.
What is the expected length of stay? *
Is the client able to consistently meet monthly program fees?*
How will program fees be paid?*
Please indicate any services the client may need so we can connect them with the appropriate resources (select
all that apply):
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.
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