Application
Housing Referral

Housing Referralinfo@gracefulwebsitedesigns.com2026-04-23T12:59:51+00:00

The Harmony Project

Housing Referral Form

The Harmony Program entry requirements: Program Participants will need to show proof of income, copy of state ID or Driver’s license. The Program participant must be independently mobile and cognitively aware.

Full Name of Referral(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Last 4 SS#:(Required)

Phone #(Required)

Email(Required)

Current Living Arrangements:(Required)

Nursing Home

Parent/Guardian Home

Assistive Living

Family/Friends

Group Home

Transitional Housing

Own House

Homeless

Rent to Own

Renting House/Apartment ( )

Other

If other, Describe your living situation.

Able to live independently?(Required)

Yes

No

Able to live independently?(Select all that apply)(Required)

Shared

Private

Were you asked to move out of your current residence?(Required)

Yes

No

If yes, Why?

Any Medical Diagnosis

Yes

No

If yes, what explain

Any Mental Health Diagnosis?(Required)

Yes

No

If Yes, What’s the diagnosis?

Drug or Alcohol Abuse:(Required)

Yes

No

Currently on Probation or Parole?(Required)

Yes

No

Need Immediate Housing?(Required)

Yes

No

If not immediate, when?

Are you actively fleeing domestic violence, stalking, dating violence, or sexual abuse?(Required)

Yes

No

Guaranteed Income:(Required)

Yes

No

Income amount(Required)

Income Source:(Required)

Select All

SS

SSI

SSDI

Retirement

Veteran Benefits

Other

If other, please list

If individual has a case manager or other provider assisting with housing, please list their name, agency and phone number:

Name/Agency

Name/Agency Phone #

Individual/Agency Referring Name:

Individual/Agency Referring Phone #

Any Additional Information:

Facebook

Page load link

Go to Top