Transitional Housing Program - Referral Screening Form
Personal Information
Legal Name *
Legal Name
(If different than Legal Name)
Phone Number *
Phone Number
Date of Birth *
Date of Birth
Gender Identity *
Gender Pronoun
Race or Origin *
Check all that apply.
Choose an option from the drop-down menu.
Sexual Orientation *
Choose an option from the drop-down menu.
Provide the name, phone number, and your relationship to this contact.
Housing Information
Have you ever lived in a shelter or temporary housing? *
Are you willing to take a drug test upon intake? *
Do you agree to mandatory substance abuse counseling if you test positive for drug use? *
Medical Information
Have you ever tested positive for HIV? *
Do you have documentation of your HIV status?
Have you ever been tested for Hepatitis C?
If yes, what was the result of your Hepatitis C test?
List the name and phone number for the doctor or clinic that you visit for care.
What is the date of your most recent lab work?
What is the date of your most recent lab work?
Insurance Information
Do you have health insurance?
If yes, what type of health insurance do you have?
Do you currently receive ADDP assistance for HIV medications?
Thank you for completing this pre-screen form for the Transitional Housing Program. Please submit this form now. A staff member will contact you shortly.