Housing Referral Transitional Housing Referral Form Applicant First NameLast NameHousehold Demographics: Please enter names and birthdates for everyone that will be living in the home. For the next several questions, please be detailed in your responses and fill out each field with as much information as possible.Reason for referral:How long has the family been homeless and how did it occur:Please explain any current or past history with drugs and alcohol for each family member:PreviousNextFUSION has a no-pet policy, does the family have any pets?FUSION has a no-smoking policy in all units and many locations do not allow smoking on premises, will this be a barrier for the family? Non-clinical barriers to permanent housing that this family must solve (I.e. legal, financial, rental history, etc..) Any evictions? How many?What are the goals that the family will work towards while at FUSION?Please provide an example of the family’s ability to focus on goals and follow through. Please be very specific about goals and plan for implementation of goals.Is there any criminal history at all, if so, what is the history? Please explain. (When did this occur and in what state and county?) What was the outcome?It is important that referred families be able to keep their unit clean and be able to get along with their neighbors. This is also a mandatory form of participation. In your experience, do you feel this family would be a good fit? Please explain why.PreviousNextCase Manager NameLast NameCase Manager Phone NumberNature and length of Relationship to Family: Agency/Organization making Referral:Agency/ Organization AddressAddress Line 1Address Line 2CityStateZip CodeFor questions, contact FUSION Program Lead Case Manager, Stephanie Barnes at case.manger@fusionfederalway.org or call (206) 406-1942 Previous Submit Form
