Client Referral Form | Housing Referrals in Ohio

Referral Source Information

* Required Fields

Date of Referral *

Referral Priority *

Routine Urgent Immediate

Referring Organization Name *

Referring Staff Member Name *

Title / Position *

Phone Number *

Email Address *

Preferred Method of Communication *

Phone Email Text

Applicant Information

* Required Fields

Full Legal Name *

Preferred Name

Date of Birth *

Age *

Phone Number

Email Address

Current Address (if applicable)

Emergency Contact Name *

Relationship *

Emergency Phone Number *

Reason & Housing Situation

* Required Fields

B. Current Living Situation *

Shelter

Family/Friends

Apartment/Home

Hotel/Motel

Vehicle

Unsheltered

Transitional Housing

Other

C. Housing Requested

Preferred Housing Option *

Private Room

Shared Room (2 Residents)

Shared Room (3 Residents)

First Available

Desired Move-In Date *

Income & Functional Eligibility

* Required Fields

A. Income & Payment Details

Primary Source of Income (Check all that apply) *

Employment

SSI

SSDI

Social Security

Veterans Benefits

Pension

Public Assistance

Family Support

Other

Estimated Monthly Income ($) *

Who is Responsible for Housing Payments? *

B. Functional Eligibility Assessment

Can the applicant independently perform activities of daily living (ADLs)? *

Yes, independently No, requires assistance

Does the applicant require 24-hour supervision? *

Yes No

Does the applicant have mobility accommodations? *

Yes No

Safety Screening & Authorization

Final Step

A. Safety Screening

Is the applicant listed on a sex offender registry? *

Yes No Unknown

Are there safety concerns for shared living? *

Yes No

B. Additional Information

C. Documents Included (Check all attached/available)

Government-Issued Photo ID

Proof of Income

Benefit Verification

Employment Verification

Housing Assessment

Case Notes

Care Plan (if applicable)

Other

Upload Supporting Documents (Optional)

Click or Drag supporting documents here Supports PDF, PNG, JPG, JPEG, DOC, DOCX up to 5MB (Multiple allowed)

D. Referral Authorization & Certification

I certify that the information provided on this referral form is accurate to the best of my knowledge. The applicant has consented to this referral and understands that submission of this form does not guarantee housing placement.

Referring Staff Member Signature *

Type your full legal name to sign digitally

Upload Signature Image

Optional: Upload a scanned signature image (PNG, JPG)

Date *

Eligible Referral Sources

Who Can Refer Clients?

I&R CARES accepts referrals from organizations, professionals, and family members working to help individuals access safe housing and supportive services.

Hospitals & Healthcare Providers
Social Workers
Case Managers
Veterans Organizations
Community Agencies
Family Members & Caregivers

INTAKE CONTACTS

Referral Email:

referrals@iandrcaresohio.org

Phone:

513-973-2428

Confidentiality Notice

Information submitted through this referral portal is used solely to evaluate referrals, determine program eligibility, and coordinate services. Access is limited to authorized staff and protected in accordance with our Privacy Policy and applicable laws.

Referral Successfully Transmitted!

Your confidential client referral has been encrypted and received by the I&R CARES intake department.

Tracking Number: #REF-2026-8942

Client Name: Client Name

Referring Organization: Agency Name

Estimated Review Time: Within 24 to 48 Hours

Connect Someone to Safe Housing & Support

HIPAA-Conscious Process

Timely Referral Review

Multiple Referral Options

I&R CARES Client Referral Form

Referral Source Information

Applicant Information

Reason & Housing Situation

C. Housing Requested

Income & Functional Eligibility

A. Income & Payment Details

B. Functional Eligibility Assessment

Safety Screening & Authorization

A. Safety Screening

D. Referral Authorization & Certification

Who Can Refer Clients?

INTAKE CONTACTS

Transmitting Referral Data

Referral Successfully Transmitted!

Submitting Application...

Submission Received!