REFERRAL

Dwell House works to transform empty houses into fully furnished homes for individuals and families transitioning out of homelessness or housing instability. This referral form helps us gather essential details to assess the family’s needs and determine how we can best support them.

Referring agencies should complete this form for families who would benefit from Dwell House services. Please provide as much information as possible to ensure a smooth process. Once submitted, a Dwell House representative will contact the family to introduce our process, confirm their needs, and schedule a home visit.

Thank you for partnering with us to create welcoming, stable homes for those in need!

REFERRING AGENCY INFORMATION

Agency Name

Staff Name

First Name

Last Name

Staff Phone Number

(###)

###

####

Staff Email

FAMILY CONTACT INFORMATION

Head of Household Name

First Name

Last Name

Phone Number

(###)

###

####

In what city is the home located?

HOUSEHOLD INFORMATION

Please complete the following to the best of your knowledge

Number of Adults in the Home

Number of Children in the Home

Specific Needs or Requirements

Does this family have any specific needs such as cribs, medical equipment, or accessibility requirements that you know of upfront? If so, please list them below.

HOUSING & STABILITY

Please complete the following to the best of your knowledge

In your professional opinion, do you believe the client is currently in or is entering stable housing?

Yes

In your professional opinion, do you believe the client has the necessary support and resources to maintain long-term stability and success?

Yes

Head of Household Employment Status

Current Housing Status

Please describe the client's current housing situation, including any housing programs they are enrolled in (e.g., Section 8, Rapid Rehousing, Metropolitan Housing, etc.).

Additional Support Programs

Please list any support programs the client is currently enrolled in that help with financial stability (e.g., SNAP, Medicaid, TANF, Ohio Works First, HEAP, rental assistance, or other relevant resources).

Has the family been informed about Dwell House and our process, including that we will be reaching out to them?

Yes, they understand and are expecting contact.

Yes, buy they need more details.

No, they have not been informed yet.

REFERRAL

REFERRAL

INFO@DWELLHOUSE.US
937 - 303 - 8005
Sidney, OH 45365

FURNISHING HOPE .

RESTORING DIGNITY.

REFERRAL

REFERRAL REFERRAL

INFO@DWELLHOUSE.US937 - 303 - 8005Sidney, OH 45365

FURNISHING HOPE .

RESTORING DIGNITY.

REFERRAL

INFO@DWELLHOUSE.US
937 - 303 - 8005
Sidney, OH 45365