Shelter of the Cross - Referral Form

Shelter of the Cross Referral Form
Date:		Name of Referred:
Referred by:		Referral Agency:
Agency Add.:		Agency Phone #:
Agency email:		Agency Fax:

Where is referred person staying now? ______________________________________________________

Is there a phone number where he/she can be reached? _________________________________________

This is to certify that __________________________________________(the referred) is:

________ Homeless or ________ At serious risk of becoming homeless (check one).

_______He/She understands and meets the Shelter of the Cross program requirements.

SHELTER OF THE CROSS ADMISSION REQUIREMENTS

The Shelter of the Cross is a transitional supportive housing program for the elderly (58 + yrs.), homeless,
or at risk of homelessness, men and women primarily from the Greater Danbury Area.

Referral Requirements for Admission are:

Homeless or at serious risk of homelessness
Capable of independent living
Fifty-eight years old or older
Sober (alcohol and drugs)
Not a danger to self or others
Willing to engage in a program to change one's life
Income under $30,000.00 a year

Please note: before admission to the Shelter of the Cross a medical clearance that states the applicant is free of any communicable disease must be obtained.

__________________________________________ Date _____________________________
Signature of Person Submitting Referral

__________________________________________
Title