Get Housing | The Homeless Project

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STOP If you have not been directed to fill out this form by The Homeless Project, please first contact Duane Mellor at 954-600-1506

Case Manager/Requestor *

First

Last

Date *

Phone Assessment Completed and Approved by Duane Mellor or Veronica Figueroa prior to form completion? *

Yes
No

This preapproval is mandatory in order to proceed with the request.

Date Completed *

Identify Respite Staff Member *

First

Last

Please type the name of the aproving Respite Staff Member.

Number of Days Requested *

Expected Admission Date to Respite *

Case Manager/Requestor Phone *

Case Manager/Requestor Email *

Supervisor Name *

First

Last

Supervisor Phone *

Supervisor Email *

Provider Name *

Section A: Demographic Information

Person Served *

First

Last

DOB *

Gender *

Male
Female
Other

SSN *

Race *

Black
White
Native American/Alaskan Native
Native Hawaiian/Pacific Islander
Asian
Multi Racial

Ethnicity *

African American
Hispanic/Latino
Jamaican
Haitian
Other

Preferred Language *

English
Spanish
Creole
Other

Benefits Status *

Currently Active
Innactive
No Benefits
Other

Explanation *

Benefits Amount $ *

Criminal Status *

Primary Income Source *

Salary
Disability
TANF
Retirement/Pension/SSI
None
Unknown
Other

Employment *

Active Military, Overseas
Terminated/Unemployed
Active Military, USA
Homemaker (must keep house for 1 or mother others)
Full Time
Student
Unpaid Family Worker
Disabled
Part Time
Criminal Inmate
Leave of Absence
Inmate Other
Retired
Not Authorized to Work

Highest Level of Education Completed *

Section B: Request Detail

Mental Health Diagnosis

Yes
No

Primary ICD-10 *

Secondary ICD-10 Substance Use Disorder

Medications (current) *

Client's Discharge Plan (After Respite) *

Discharge Plan Supporting Documentation *

RTF, ALF, AFCH
Friend/Family Verification
Other

Upload Documentation

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