Housing & Transitional Placement Referral

01Referring Case Worker Information

Referring Agency / Division *

Milwaukee Mental Health Emergency Center Veterans Affairs / Veteran Services Dept. of Corrections / Probation & Parole Homeless & Shelter Services Mental Health / Community Provider Other

Please select the referring agency.

Case Worker Name *

Please enter your name.

Program / Grant Name

Direct Phone *

Please enter a valid phone number.

Email *

Please enter a valid email address.

02Applicant Information

Full Legal Name *

Please enter the applicant's full legal name.

Phone

Date of Birth

Gender

Male Female Non-binary / Other

Current Living Situation

Emergency Shelter Encampment / Unhoused Hospital / Treatment Incarcerated Doubled Up / Transitional

03Requested Housing Placement

Desired Facility *

Residential / Community House Bed The Carbon Residences (2224 W. Kilbourn Ave) First Available / Either

Please select a desired facility.

Target Move-In Date

04Safety & Background Screening (Required)

Has the applicant ever been convicted of, or is currently charged with, any of the following?

1. Violent Crimes *

Yes No

2. Crimes Against Children *

Yes No

3. Arson or Property Destruction *

Yes No

Please answer all three screening questions.

If YES to any of the above, please provide context (dates, nature of offense, outcome)

05Financial & Funding Details

Payment Responsibility

Housing Voucher (HUD-VASH, Housing Choice, etc.) Agency / Program Third-Party Direct Pay SSI / SSDI / Employment (Self-Pay) Other Subsidy / Grant

Payer / Funding Agency Name

Voucher / Case ID Number (if applicable)

Approved Monthly / Weekly Rate Covered ($)

Pay Status / Approval Stage

Active & Approved Pending Verification In Application Process

06Substance Use & Mental Health Services

Is the applicant currently receiving alcohol or drug treatment/counseling?

Yes No

If YES — Treatment Provider / Counselor Name

Does the applicant require or benefit from a sober recovery housing environment?

Yes No

Is the applicant actively connected to outpatient mental health care?

Yes No

07Level of Care & Accessibility Needs

Living Independence

Independent Living — capable of daily self-care, cooking & medication management without assistance Supportive Needs — requires light assistance or ongoing case management guidance

Accessibility Needs

ADA Unit Required (wheelchair accessible, roll-in shower, ramp, ground floor) Standard Unit (Non-ADA)

Specific Accommodations / Medical Equipment Needed

08Case Worker Authorization & Notes

Please detail any immediate needs, behavioral considerations, or stability supports required

Case Worker Signature (type full name) *

Please type your full name as your signature.

Date *

Please enter today's date.

Housing & Transitional Placement Referral Form

01Referring Case Worker Information

02Applicant Information

03Requested Housing Placement

04Safety & Background Screening (Required)

05Financial & Funding Details

06Substance Use & Mental Health Services

07Level of Care & Accessibility Needs

08Case Worker Authorization & Notes