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Housing 
Stabilization Referral

Please fill out the following Housing Stabilization referral form for our team to review. 

If you would like a PDF version of this referral form to fax, please email us at info@harmonyhomesservices.com

Please fill out all the indicated areas.

Referring Party

General Information

Gender

Brief Questionnaire

Legal & Guardianship Status
Waivered or Non-waivered
If non-waivered, is there an existing PSN (Professional Statement of Need) document?

* If no, we can help with
obtaining a PSN document.

Current drug & alcohol use?
Existing criminal background history
Religious & Cultural Preferences?
Interested in what type of Housing Stabilization Services?

Housing Situation

Currently homeless or at risk of homelessness?
Currently leasing?

ADDITIONAL INFORMATION

Team Contact Information:
Leave field empty if not applicable.

Emergency Contact Information

Waiver Case Manager

Legal Guardian/Representative

Please upload all available supporting documents to ensure timely initiation for housing stabilization services.

Upload File
Upload File
Upload File
Upload File

Thanks for submitting! We will review and get back to you within the day!

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