For Case Managers

Referral Intake Form

Designed for case managers at hospitals, jails, and social services to facilitate rapid placement (typically 24-48 hours) for individuals in need of supportive housing.

Compliance Ready

Complies with Arlington Ordinance No. 25-020 and HUD-VASH requirements

Fast Processing

24-48 hour turnaround from referral to placement

Populations We Serve

Veterans

HUD-VASH vouchers accepted

Seniors (55+)

Independent living capable

Adults with Disabilities

Independent living capable

Compliance Notice

This form complies with Arlington Boarding Home Facility Ordinance No. 25-020 and federal housing programs including HUD-VASH requirements.

Referral & Population Data

Applicant Full Name *

Date of Birth *

Current Location *

Population Category *

VeteransSeniors (55+ years)Individuals with Disabilities

Referral Agency Information

Agency Name *

Case Manager Name *

Phone *

Email *

Functional Independence Assessment

Mandatory: Arlington boarding homes cannot provide personal care services. Residents must be capable of independent living.

Activities of Daily Living (ADLs)

Can the applicant eat without assistance? *

YesNo

Can the applicant bathe without assistance? *

YesNo

Can the applicant dress without assistance? *

YesNo

Can the applicant move/transfer without assistance? *

YesNo

Emergency Response

Can the resident self-evacuate the building in the event of a fire? *

YesNo

Medication Self-Administration

Can the applicant identify their medication? *

YesNo

Can the applicant state the reason for their medication? *

YesNo

Can the applicant distinguish the correct dosage and time? *

YesNo

Storage Acknowledgment *

I acknowledge that all medications will be kept in a locked storage area provided by the facility.

Financial & Assistance Status

Income Source *

SSISSDIPensionEmployment

Total Monthly Income Amount *

Housing Assistance

Does the resident have an active Housing Choice Voucher (HCV) or HUD-VASH voucher? *

YesNo

Safety & Conduct Screening

Is the applicant a registered sex offender? *

Important: PHAs must deny admission to any household containing a lifetime registered sex offender.

YesNo

Sobriety Commitment *

The resident agrees to a 100% drug and alcohol-free environment and understands the "strike and discharge" policy.

Household Rules Agreement *

The resident agrees to participate in weekly inspections and shared chores.

Medical & Support Needs

Dietary Requirements

0/500 characters

Special Accommodations

0/500 characters

Emergency Contact

Contact Name *

Contact Phone *

Relationship to Applicant *

Need Help?

If you have questions about this form or need assistance, please contact us:

(817) 382-2483 Info@myresidentialjourney.com

My Residential Journey

Providing dignified, supportive housing for individuals in need throughout the Dallas-Fort Worth area.

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