Referral - Hope First Housing

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SUBMIT REFERRAl

Referral

Help someone take the next step toward safe, supportive housing.

Submit A Referral

If you’re a case manager, social worker, healthcare provider, or family member referring someone to Hope First Housing , please complete the form below. Our intake team will follow up promptly to begin the process.

Referring Party Information

Full Name (Referring Party)(required)

Organization / Agency Name (if applicable)

Phone (Referring Party)(required)

Email (Referring Party)(required)

Relationship to Client (e.g. Case Manager, Social Worker, Family Member)(required)

Client / Applicant Information

Full Name (Client/Applicant)(required)

Preferred Name (if different)

Date of Birth (MM/DD/YYYY)(required)

Gender Identity(required)

Phone (Client/Applicant)(required)

Email Address (Client/Applicant)

Preferred Language

Current Living Situation (e.g. Homeless, Couch-surfing, Shelter, Hospital, Jail, Currently Housed, etc.)

Housing Needs & Support

Reason for Referral / Brief Client Background (include current challenges or needs such as mental health, substance use, medical, reentry, etc.)(required)

Type of Housing Requested (Check all that apply)(required)

Veteran Housing Group Home Senior Living Sober Living Assisted Living-Style Support Transitional or Reentry Housing

If not in the type of housing options above, please specify:

Does the client receive any of the following?(required)

SSI/SSDI General Assistance VA Benefits Section 8/Other Housing Voucher None Unknown

Does the client currently have a case manager or service provider?(required)

Yes No

If yes, please provide contact info:

Full Name (Case Manager)

Phone (Case Manager)

Email (Case Manager)

Additional Notes

(Behavioral needs, accessibility, medication management, etc.)

By submitting this form, you agree to our processing of your data in accordance with our Privacy Policy.

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Creating Safe, Supportive, and Affordable Housing for All

WHO WE SERVE

Individuals with Diverse Needs
Veterans
Elderly and Senior Care
Sober Living

CONTACT INFORMATION

Feel free to contact & reach us!

2991 SACRAMENTO ST # 215
BERKELEY, CA 94702

Telephone : (661) 387-3680

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