Referral Form – H2H ONE | Heels to Halos

Halo House Referral Form

Exclusions
-Must be 18 or older
-Cannot be currently pregnant

Referring Agency *

Point of Contact Full Name *

Point of Contact Phone Number *

Point of Contact Email *

What is the relationship of the woman you are referring?

How did you come into contact with the client?

How did you hear about the Halo House?

Name *

First

Last

Phone *

Date of Birth *//

Must be over 18.

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Please describe her current living situation.

Is she currently residing with anyone? If so, who?

Is she married?

Has she attempted suicide/entertained the idea within the last 6 months?

Has she been detoxed form drugs/alcohol for 3 months or more?

Has she ever been in another safe house before?

Does she have transportation?

Does she have up to date identification?

Does she have any pending court dates?

Is she pregnant?

Does she have any children?

Is she currently caring for her children?

Is she incarcerated?

Is she currently on probation?

Does she currently have any warrants?

Does she have family in the Houston area?

Is she currently in a stable mental and physical state?

Does she currently seem to be a threat to herself or concern for self harm?

Please list any and all prescribed or non-prescribed medication she is taking.

Is there a specific drug addiction we should be aware of?

Does she have a pimp?

Is she in immediate danger? *

What are her immediate needs?

Does she need temporary safety or long term residential housing?

Have you told her who we are and we are a faith based organization?

Is she willing to not have any cell phone, phone calls, email, or social media?