GOLDEN YEARS HAVEN REFERRAL FORM 
Welcome! 
We are so excited to collaborate with you in the important work of helping others secure safe, clean and drugfree housing. 

We are a family-ran business that aims to serve a low-income, SSI or SSDI and our veteran population that is in need of housing and a community. 

If you have someone who might be a good fit for our homes, please fill out the form below and someone will be in contact soon! 

If you have immediate questions, please don't hesitate to reach out to us at:
INFO@GOLDENYEARS-HAVEN.COM
Email *
In what area are you looking for supportive housing? *
1 point
Referrer's Information
Full Name:
Organization/ Agency Name  *
Position/ Role/ Title 
Business Address 
Phone Number  *
Contact Email  *
Relationship to Intending Resident? *
Intending Guest- General Information
Please include client information below
Full Name / Nickname *
Gender Identity *
Phone Number *
Intending Guest Email 
Secured Intending Resident Information 
Date of Birth
MM
/
DD
/
YYYY
SSN/TIN (if Available) 
Marital Status* *
1 point
Financial Information 
Please Provide Monthly Income Information (How much and Sources) *
Is the Intending resident on Probation or Parole?*
Clear selection
If yes, please provide information: 
Probation Officer Name
Probation/ Parole Contact Number 
CDC# 
End Date:
Is the intended resident able to carry out basic daily activities independently? *
Required
Golden Years Haven provides residence ONLY, please tell us other forms of care the intending resident may need and we will work to refer them to other licensed providers: 

 *
Required
Does the Intending guest receive food stamps (SNAP)?
Clear selection
Is the Intending resident recovering from any addiction that we should be aware of? 
Clear selection
If Yes, what addiction(s)?
Intending Resident's Emergency Contact Information 
Emergency Contact Full Name  *
Phone Number  *
Email *
Relationship to Intending Resident 
Should resident violate any rules warranting IMMEDIATE removal such as drug use, or violence towards another house guest, where would they like to be relocated to? 
Please provide address and support person below: (MUST PROVIDE)
 *
Any other information we should know about the resident- including medical conditions, illnesses or conditions to improve our support for this guest?
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