Join Our Housing Waitlist for Safe Living Options

Referring Agency*

Case Manager / Referrer Name*

Phone *

Email *

Preferred mode of contact*

Phone

Email

Both

Client's full name*

Date of Birth*

Gender*

If "Other" explain

Does the client manage meals independently?*

Yes

No

Does the client manage medications independently?

Yes

No

Does the client require caregiving or clinical services?

Yes

No

Client’s Income Source:*

SSI/SSDI

VA Benefits

Employment

Other

If "Other" please explain, writhe N/A if not applicable*

What is your monthly income?*

Is the client currently facing any pending legal charges?*

Yes

No

If "yes" explain

Is the client currently under any supervision as listed below?*

Parole

Probation

None

Other

If "Other" explain, write N/A if not applicable*

Has the client ever been convicted of any type of violence or sexual offence?*

Yes

No

If "Yes" explain

Is the client willing to share a room?*

Yes

No

Is the client able to provide a valid ID, SSN, and proof of income?*

Yes

No

If "Yes" explain

Has the client ever been diagnosed with a mental health condition?*

Yes

No

If "Yes" does the client have a treatment or medication plan in place?*

Yes

No

Has the client ever struggled with alcohol, drugs or substance use in the past?*

Yes

No

Is the client sober?*

Yes

No

if "Yes" how long?*

What is the Clients current housing situation?*

Homeless

At risk of eviction

Discharged from hospital or facility

In transition housing

Other

If "Other" explain or write N/A*

What population type below does the client identify with?*

Veteran

Senior

Sober living

Re-entry

Cognitive and developmental disabilities

Foster youth transition

Survivor of domestic violence

Other

If "Other" explain or write N/A*

Expected Move-In Timeline*

Within 30 days

1–3 month

3–6 months

6+ months

Is there anything else you would like us to know? *

Disclaimer & Attestation: By submitting this form, I certify that the information provided is true, accurate, and complete to the best of my knowledge. I understand that Empowered Community Living provides housing-only, peer-supported independent living and does not offer meals, caregiving, supervised medication, medical care, or clinical services. Participation is by program agreement, not a landlord-tenant lease. I authorize Empowered Community Living to contact me by phone, email, or text message regarding housing, referrals, or program participation. I may opt out of communications at any time by replying STOP or by contacting Empowered Community Living directly.*

I agree to the above disclaimer

Submit Your Referral Today

Fill out the form below to get started. Refer someone ready for peer-support housing only—no clinical or personal care services included.