Client Support Referral Form

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Thank you for taking a moment to complete this referral form. This information helps us connect individuals and families to the appropriate support services offered through the Christian Development Center.

Please ensure that you or the person you are referring meets at least one of the following situations.

1. Currently without stable housing, at risk of losing housing, or escaping an unsafe living environment.

2. Receiving or eligible for long-term housing support through a local coordinated entry system.

3. Enrolled in Enhanced Care Management and living with a significant medical, mental health, or chronic condition

4. In need of residential care or assistance due to substance use challenges.

5. A young adult facing obstacles that make stable housing difficult to maintain.

Once submitted, a member of our team will contact you within 3 business days to review the information provided and discuss next steps for accessing support services.

If you have questions or need help completing this form, please call us at 909-236-5403

Who are you submitting this request for?

Myself

A Family Member

A Friend

On Behalf of a Client

Clear selection

Todays Date :

YYYY

What type of services are requesting?

Housing Assistance (Housing Navigation, Deposits, Tenancy & Sustaining)

Community Health Worker( Community Resources, Health Education/Navigation, Support or Advocacy

Both

Members First Name:

Members Last Name:

Phone Number:

Medical Coverage Provider( Health Plan Name) :

IEHP

Kaiser

Molina

Other

Clear selection

Member # or Medi-cal #

Kaiser Member ? (Only select if applicable):

Yes

Date of Birth:

Zip Code:

Email Address (optional)

If you are submitting on behalf of an organization, please share your details below:

Full Name:

Organization Name:

Phone Number:

Please describe your (or the member's) current housing situation:

Authorization to Proceed:

Checkbox

I give permission to Christian Development Center to review and process this referral. I understand that someone from the office will contact me to confirm the information provided before any services are arranged.

Submit

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