Refer a Client to Next Chapter Haven

For social workers, case managers, discharge planners, and reentry coordinators. Please complete all required sections. Our intake team responds within one business day.

1. Referral Partner Information

Organization Name *

Contact Person *

Job Title

Phone Number *

Email Address *

Organization Type *

2. Client Information

Client First Name *

Client Last Initial *

Age *

Gender

3. Current Housing Situation

Select all that apply.

ShelterHospitalTransitional HousingReentry ProgramFamily / FriendsHomelessOwn ResidenceOther

4. Desired Housing

Room Type *

Shared RoomPrivate RoomEither

Move-in Timeline *

ASAPWithin 7 DaysWithin 30 DaysFlexible

5. Funding Source

Select all that apply.

SSISSDIJob-Related IncomePrivate PayVA BenefitsAgency FundingGovernment AssistancePensionOther

6. Eligibility Screening

Referral partner must confirm all of the following apply to the client.

Client is 18 years or olderClient can live independently without 24-hour supervisionClient agrees to a drug-free environmentClient agrees to an alcohol-free environmentClient agrees to a weapon-free environmentClient understands this is shared independent living housingClient is willing to follow house rules

7. Safety & Clinical Screening

Does client require 24-hour supervision? *

YesNo

Does client require skilled nursing care? *

YesNo

Does client require personal care assistance? *

YesNo

Does client require medication administration? *

YesNo

Are there behavioral or safety concerns we should be aware of? *

YesNo

8. Additional Notes

Notes

Before Submitting

Next Chapter Haven provides:

Safe structured housing
Drug-free environment
Alcohol-free environment
Weapon-free environment
Independent living only (no medical or personal care services)

I certify the information provided is accurate to the best of my knowledge. *

By submitting, you confirm you have appropriate authorization to share this client's information for placement purposes.