Placement Referral Form

If you are assisting a veteran or senior in need of housing support, please enter their information below. Our team will review the referral and coordinate appropriate next steps directly with you or the individual.

Referral Submitted By *

Email *

Organization / Agency Name *

Prospective Resident Name *

Contact Info *

Is the applicant a member of the senior age demographic (55 years or older)? *

Yes

No

Room Type *

Shared

Private

Is the applicant a U.S. Veteran? *

Yes

No

Branch of Service

Years Served

VA Connected *

Yes

No

VA Benefits Active *

Yes

No

Valid identification *

State ID

Social Security card

Birth Certificate

None

Monthly Income Amount: *

$

Does the applicant have mobility or medical needs that require accommodations? *

Yes

No

Does the applicant have family members or children who may visit with them? *

Yes

No

Has the applicant experienced challenges with drug or alcohol use? *

Yes

No

Is the applicant currently using drugs or alcohol? *

Yes

No

Is the applicant currently enrolled in a treatment or recovery program? *

Yes

No

Name

Contact Information

Does the applicant currently work with a sponsor or recovery coach? *

Yes

No

Name

Contact Information

Will the applicant commit to living in a shared, substance free community setting? *

Yes

No

Has the applicant signed a Release of Information (ROI) permitting communication between WillowNest Independent Living and your Agency? *

Yes

No

Pending

With the applicant’s permission, are you able to provide any medical or support information that may affect housing placement? *

Yes

No

N/A

Agency Support Commitment: Should the applicant face behavioral or compliance challenges, will your agency participate in a case conference or offer intervention support? *

Yes. We will provide follow-up support

No. Our involvement ends with this referral

Referral Agreement & Acknowledgment

By submitting this referral, I confirm that:

You agree to partnership with WillowNest Independent Living.
Applicant meets criteria for independent, sober, and stable living.
Applicant agrees to WillowNest Independent Living’s community standards.

I have read and agree to the above statement.

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