REFERRAL FORM - Shelter Care



SCM – Careers & MORE works with adults who are homeless, at risk, and economically disadvantaged parents of minor children, teaching them to overcome barriers, secure gainful employment, and attain self-sufficiency.

1. Applicant’s full name 2. SSN

3. Referring agency 4. Contact person

5. Phone # 6. Fax # 7. Email 8. Date issued / /

9. Referral source: (Self ( Gov. Agency: ______________ ( Hospital or medical clinic staff

( Street outreach/church worker ( Alcohol or drug treatment program ( Police/Probation/Parole/SRC

( Emergency/transitional shelter staff ( Other social service staff, specify: ( Supportive Housing/Public housing waiting list

( Psychiatric in/outpatient facility _______________________________ ( Other __________________________________

Applicant Info: 10. Address Apt./room # 11. Phone #

12. City/Zip: / 13. Housing is: (Temporary ( Permanent

14. Housing: ( Streets ( Halfway house ( Supportive housing ( Emergency shelter ( Transitional housing ( Own/rent ( Relative/friend

( Other 15. How long at this location? 16. Are you receiving housing assistance? (Yes ( No

17. Gender: ( M ( F 18. DOB: _____/_____/_____ 19. Last grade completed: ______________ 20. Marital Status: ( M ( S

21. Dependents: ( Spouse ( Children # _____ ( Other # 22. Dependents living with applicant # ________

23. Currently employed? (Yes ( No 24. Monthly household income $__________ 25. On parole? (No ( Yes IDOC # _____________

26. Race (check all appropriate): ( Black ( White non-Hispanic ( Hispanic ( Native American ( Asian ( Slavic ( Other ______________

27. Applicant special needs: ( addiction treatment ( anger management/domestic violence/abuse ( learning disability/literacy ( Ed/GED

( diagnosed disability ( health/dental care ( clothing ( transportation ( housing ( criminal record ( other _____________________

28. Is program completion required for continuation of your services? ( Yes ( No 29. Do you require a weekly status report? ( Yes ( No

NOTE: Status reports are generated by email or fax only. Please provide complete information if you wish to have a status report forwarded to you.

As a representative of the referring agency I certify, to the best of my knowledge, the above information is true and accurate.

REQUIRED: Signature – Agency Representative/Case Worker Date

PLEASE FAX THIS COMPLETED REFERRAL TO SHELTER CARE MINISTRIES APPLICANT MUST CALL FOR AN APPOINTMENT.

FOR PLES OFFICE USE ONLY

29. Intake assessment scheduled for / / @ ______ AM / PM 30. Scheduled for PEC on: ______/______/_____

31. Programs eligible for: ( Homeless ( At Risk ( UW ( Other (specify) __________________________________________ ( NONE

32. Not enrolled: ( Refused ( Did not show ( Did not meet requirements (specify) _______________________________ ( Unknown

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