Referral Form – Chattanooga Room in the Inn

Client Information

Name *

First

Middle

Last

DOB *//

Other names client may go by:

Nickname or Maiden Name

Contact number for person being referred:

Provide if applicable

Current Family/Individual’s annual income ($): *

Client Details

For how long have you known this individual? *

What is your relationship with the person you are referring? *

Has a VI-SPDAT been performed? *

Does this individual meet the program admission guidelines? *

Describe the situation causing this person to experience homelessness: *

Where is this person staying currently? *

How many times has this person experienced homelessness? *

Has this person been to CRITI before? *

Has this person been to any other shelter? *

Names and agencies this client is currently working with: *

Medical Issues: *

Include anything that would prevent client from walking up and down stairs or completing daily chores/explain:

Medications prescribed:

Is this person capable of caring for themselves? *

Does the client have any previous or existing mental health issues? *

Does the client have previous or existing Alcohol/Drug issues? *

Criminal History:

Is the person being referred eligible for housing? *

Client Education

Highest Level of Education Completed:

Can the person being referred read and write?

Child(ren) Information

Does this person have children living with them? *

Any additional information?

Referral Source Information

Referred by:

Name *

Agency *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

Sign & Submit Referral Form

I authorize the use of the information in this application to verify information for a volunteer position at Chattanooga Room in the Inn.

Signature *

Please type your full name.

Date/Time:

Required Referral Form for Admission Consideration