Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Contact Number

(###)

###

####

In Search Of *

(choose all that apply)

Emergency Shelter (Please call our hotline 505-504-1301 if you haven't already)

Intake into Temporary Housing/Transitional Living

Case Management

Current Housing Status *

Independent housing

Transitional living

Shelter

Hospital/corrections facility

Street/car

Place not meant for habitation

Other

Substances Used Regularly *

Heroin

Methamphetamine

Marijuana

Cigarettes

Fentanyl

N/A

Other

Willing to seek help for substance use? *

Yes

No

N/A

Last Date of Substance Use

If applicable

MM

DD

YYYY

Does the referred client have access to their personal I.D.? *

Yes

No

Does the client currently have any outstanding warrants or legal obligations? *

Yes

No

Has the client been a victim of sex trafficking? *

Yes

No

Unknown

Is the trafficker in custody?

If above answer is yes

Yes

No

N/A

Is the client currently self-harming? *

Yes

No

Unknown

Does the client have a history of suicidal ideation? *

Yes

No

Unknown

Can the client safely live independently? *

Yes

No

Unknown

Our transitional program is scattered site apartments, clients referred must be able to live independently without 24/7 supervision. Clients must be willing to share the apartment with 1 other individual and follow the transitional apartment rules which include not sharing the location of the apartment and not bringing anybody to the apartment. *

I, as the interested individual, understand the above statement and acknowledge that I am physically capable of living independently and willing to share the space with another individual. As well as follow the rules listed above.

I, as the referring agent, understand and will explain the above statement to the individual I am referring prior to submitting an official referral

Not applicable, not looking for transitional housing.