Housing Services Referral Form – The Lotus Center, Inc.

Name *

First

Last

Date of Birth *

Layout

Phone *

What does your living situation look like right now? *

Check all that apply in your current housing environment.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Where can you/client can be found during the day? *

Are you a Minnesota or North Dakota resident? *

If you referred by an agency, who referred you? *

If you were not referred by another agency, use N/A

Do you have felonies on record? *

Yes
No
Unsure

If yes, when were you charged?

Do you anticipate any felony charges?

Email *

Gender *

Woman
Man
Non-Binary
Prefer not to say

Preferred Pronouns

Do you have Health Insurance coverage? *

Yes
No
Would like assistance applying for health insurance.

Emergency Contact Name

First

Last

Emergency Contact Phone Number

Are you working with another agency for housing services? *

Yes
No

If yes, what agency and case manager are you working with? Please also include their contact information.

Scheduling Preferences

If there are certain times that work best with your schedule include them here.

Do you/your client have a mental health diagnosis? *

Yes
No
Unsure

Are you/your client currently seeing a mental health provider? *

Yes
No
Unsure

Do you already have a professional statement of need (PSON)? If so, please attach below.

Click or drag files to this area to upload. You can upload up to 10 files.

Have you been previously homeless? *

Yes
No

How many people are in your household? *

Please include adults (older than 18) and children (Under 18).

Do you have pets? *

Yes, Dog
Yes, Cat
No

Are you employed? *

No
Yes, Part-time
Yes, Full-time

What is your income? *

Using government benefits? *

Yes
No

Do you have transportation? *

Are you receiving treatment at The Lotus Center? *

Yes
No

If yes, what group are you attending?