Halo House Referral Form Exclusions-Must be 18 or older-Cannot be currently pregnant Please enable JavaScript in your browser to complete this form.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?Potential Halo InformationName *FirstLastPhone *Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Must be over 18.Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePlease describe her current living situation.Is she currently residing with anyone? If so, who?Is she married?YesNoHas she attempted suicide/entertained the idea within the last 6 months?YesNoHas she been detoxed form drugs/alcohol for 3 months or more?YesNoHas she ever been in another safe house before?YesNoDoes she have transportation?YesNoDoes she have up to date identification?YesNoDoes she have any pending court dates?YesNoIs she pregnant?YesNoDoes she have any children?YesNoIs she currently caring for her children?YesNoIs she incarcerated?YesNoIs she currently on probation?YesNoDoes she currently have any warrants?YesNoDoes she have family in the Houston area?YesNoIs she currently in a stable mental and physical state?YesNoDoes she currently seem to be a threat to herself or concern for self harm?YesNoPlease 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?YesNoIs she in immediate danger? *YesNoWhat are her immediate needs?Does she need temporary safety or long term residential housing?TemporaryLong TermHave you told her who we are and we are a faith based organization?YesNoIs she willing to not have any cell phone, phone calls, email, or social media?YesNoSubmit