NEIGHBORHOOD HOUSE HOMELESS PROGRAM
HOW TO REFER A FAMILY
Thank you for your interest in referring a family to our homeless program. Please complete the
following information with the family you have in mind. If you are an emergency shelter, then we
expect a minimum of 7 days, any other providers we expect a minimum of 30 days regarding working
with the family before making the referral. By making this referral you are stating you have known
the family long enough to know they would be a good fit for the program.
Answer all questions to the best of your ability. Do not leave blank spaces.
Incomplete applications will not be accepted.
The form must be faxed back to our office at 503-946-9922.
The process will be as follows:
1.
Completed referrals will be evaluated for eligibility.
2.
A confirmation receipt will be faxed to the referring person within 10 working days. The
confirmation will state if the family is eligible for further review and for which program
they may qualify for.
3.
Eligible families can be placed on our program waiting lists for up to 2 months. If
additional time is necessary, please provide an explanation so that the referral can be
extended. Placement on the waitlist does not guarantee the family will receive
assistance.
4.
Please do not call to find out length of time on the waitlist. We cannot estimate the
length of time on the waitlist, as it is dependent on the success of families currently
enrolled in the program.
5.
Under no circumstances will we contact the client directly without going through the
referring person. For this reason, we ask that you encourage your client to keep you
informed of any changes in contact information.
6.
Once the family comes up on the waitlist, we will email the referring person who has 3
working days to respond.
Please take into consideration that we offer a complete program and the family being referred must
be ready for change.
Only homeless families(HUD definition) may be referred.
Families may be denied for the following reasons: no children or verifiable pregnancy, 3 or more
evictions, violent offenses, registered sex offenders, convicted in manufacture and/or delivery of a
controlled substance, have an open warrant, have more than $3,000 in landlord debt, or are in need
of a safe house.
Giving false information will result in the immediate denial of the application.
Please keep the top page as a reference
TRANISITONAL HOUSING REFERRAL FORM
(TO BE COMPLETED BY REFERRING AGENCY)
PLEASE PRINT LEGIBLY / DO NOT LEAVE BLANK LINES
Name of referring case worker/person: ______________________________________________________________________
Agency name: _______________________________________________________________ Phone #: ________________________
Position: _____________________________________________________________________ Fax #: ___________________________
Email address: __________________________________________________________________________________________________
Family being referred: _________________________________________________________________________________________
How long have you known this family? (emergency shelter minimum of 7 days / all others minimum
of 30 days): ________________________________________________
How did you begin working with this family? _______________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
What services are you currently providing for this family? _________________________________________________
____________________________________________________________________________________________________________________
What services will you continue providing after placement into program? _______________________________
____________________________________________________________________________________________________________________
Are you able to participate in joint meetings with the family and our staff to coordinate services and
case planning? ( ) YES ( ) NO
What have you observed the family strengths to be? _______________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
In your opinion, why do you feel the family will be appropriate for our homeless program? ___________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
What goals do you feel the family should work towards while in the program? __________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
What concerns do you have with this family? _______________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Additional comments: _________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Checklist:
☐
all questions complete
☐
Release of Information to Neighborhood House is attached
☐
Copy of police report (must submit a minimum background check for the county
they have primarily been residing in)
☐
Verification of homelessness
Choose only 1 option
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☐
☐
Turning Point
I understand the apartments are small one bedroom efficiencies and are located in
SW Portland
I understand that the program consists of intensive case management focused on
increasing income, gaining self sufficiency, and securing permanent housing
I understand that the family will pay 30% of their adjusted gross income to rent and
another third of their income into a mandatory savings account
If no minor dependent child(ren) are in the family’s physical custody, the family will
provide a letter from DHS child welfare/relevant party stating that custody will be
returned within 14 days of program or a statement verifying pregnancy from a
primary care physician.
Scattered Site
The family has physical custody of a minor dependent child
The family has been homeless for the last 7 days in Multnomah County: staying in a
shelter, vouchered into a hotel by an agency, camping, or living on the streets
Homes Not Beds
The family has been homeless for a total of 6 months in the last 3 years (not
counting living with family/friends)
The head of household has a verifiable physical or mental disability, including but
not limited to those caused by alcohol or drug use
If the family does not have physical custody of a minor dependent, the family will
have physical custody of a minor dependent within 90 days of being placed of
housing verified by DHS child welfare
By signing this referral form, I understand that the information is true to the best of my knowledge. I
am recommending the family to the homeless program and I believe they will make the necessary
changes to improve their homeless situation.
____________________________________________________________________________________________________________________
Signature
Date
TO BE COMPLETED BY FAMILY
PLEASE PRINT LEGIBLY / ANSWER ALL QUESTIONS
Name/ head of household: ____________________________________________________________________________________
Date of birth: ________________________ Age: _________________
Please list all family members who will move into the household immediately
Name: ___________________________________________________________________________________________________________
Relationship: ____________________ Date of birth: ______________________ Age: _______________________
Name: ___________________________________________________________________________________________________________
Relationship: ____________________ Date of birth: ______________________ Age: _______________________
Name: ___________________________________________________________________________________________________________
Relationship: ____________________ Date of birth: ______________________ Age: _______________________
Name: ___________________________________________________________________________________________________________
Relationship: ____________________ Date of birth: ______________________ Age: _______________________
Name: ___________________________________________________________________________________________________________
Relationship: ____________________ Date of birth: ______________________ Age: _______________________
Please list all family members who will move into the household at a later date
Name: ___________________________________________________________________________________________________________
Relationship: ____________________ Date of birth: ______________________ Age: _______________________
Reason for moving in later: _________________________________________________________________________
Name: ___________________________________________________________________________________________________________
Relationship: ____________________ Date of birth: ______________________ Age: _______________________
Reason for moving in later: __________________________________________________________________________
When did you become homeless (approximate date)? __________________________________
Please check where you are currently residing?
( ) Emergency Shelter ( ) Hotel being paid for by an agency ( ) On the streets
( ) Hotel being paid by self ( ) Institution
( ) Being evicted through the courts within 14 days
( ) Fleeing Domestic Violence ( ) Residing with Friends/Family
How did you initially become homeless? _____________________________________________________________________
____________________________________________________________________________________________________________________
Is this the first time you have experienced homelessness? ( ) YES ( ) NO
If not, how many times have you experienced homeless in the past? __________________
Please explain those circumstances? ________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
What has prevented you from renting your own home? ___________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Do you have any evictions on your record? ( ) YES
( ) NO
**Not eligible for program if more than 3 evictions or owe more than $3,000 in landlord debt**
Date: _________________________ Address: ______________________________________________________________
Reason for eviction: __________________________________________________________________________________
Amount owed to landlord: $ _____________________
Date: _________________________ Address: ______________________________________________________________
Reason for eviction: __________________________________________________________________________________
Amount owed to landlord: $ _____________________
What steps have you taken to overcome your homelessness? _____________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Are you on any affordable housing waitlists in the area? Please list: ______________________________________
____________________________________________________________________________________________________________________
Source of income:
_______________________________________
$ _____________________
_______________________________________
$ ____________________
_______________________________________
$ ____________________
Food stamps
$ ____________________
Please list any criminal charges:
**Not eligible for program with violent offenses, are a registered sex offender, and/or convicted in
manufacture and/or delivery of a controlled substance, or have an open warrant**
Name: ____________________________________________________________ Date: _____________________________
Charge: ____________________________________ Disposition: _____________________________________________
Name: ____________________________________________________________ Date: _____________________________
Charge: ____________________________________ Disposition: _____________________________________________
Name: ____________________________________________________________ Date: _____________________________
Charge: ____________________________________ Disposition: _____________________________________________
Please complete the following chart so that we know what other agencies you are receiving services
from:
TANF
Worker: _____________________________________________________________________________ Phone: ___________________
DHS (Child Services)
Worker: ______________________________________________________________________________ Phone: __________________
Parole/Probation
Worker: ______________________________________________________________________________ Phone: __________________
DV Counselor
Worker: ______________________________________________________________________________ Phone: __________________
A&D Counselor
Worker: ______________________________________________________________________________ Phone: __________________
Please explain in your own words what you hope to gain from participating in our homeless
program:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Please list a few primary goals you would like to work on while in the program:
1.
_____________________________________________________________________________________________________
2.
_____________________________________________________________________________________________________
3.
_____________________________________________________________________________________________________
I understand that by signing this form I/we are giving permission to the referring agency to disclose
information to Neighborhood House that would help with placement into one of the housing
programs. I/we have completed this form to the best of my/our ability and all information is true to
the best of my/our knowledge. I/we understand that knowingly providing false information will
result in denial of any further consideration.
____________________________________________________________________________________________________________________
Head of household signature
Date
____________________________________________________________________________________________________________________
Other adult signature
Date