HC Referral form

The Community: 28 two, three, and four bedroom townhomes in the North Glenmore area of Kelowna BC. This community is drug and alcohol free and vaping and cigarette smoking is permitted in the designated outside smoking area only. Hall Crossing is a gated community with a clubhouse, programming and onsite supports.

Tenants: Female-led families who have been impacted by domestic violence and could benefit from safe housing attached to supports.

Referrals: Accepted from community partners on behalf of clients.

Please Note: Hall Crossing is a program with expectations such as monthly meetings with the Family Support Worker, mandatory workshop attendance, and monthly home inspections. The Participant will be expected to set goals for herself and her children and work with the FSW to achieve them. Anyone not requiring or needing this kind of support would not be a suitable candidate for this program.

Referring Agency and Contact Information:

How long have you been working with this family?

Applicant first and last name

Applicant birthday

Year

Month

Day

Applicant phone

List all other household members with dates of birth and gender:

Please state any known safety concerns:

Does the applicant have issues with substances? If yes please explain:

Any known criminal history?

Current court involvement? (criminal, family court etc.) If yes, please explain.

Please list any Mental Health diagnoses, or concerns:

Any physical health impairment or mobility issues?

Does this applicant have the ability to live independently?

Source and amount of Monthly Income:

Explain why you think this family is a fit for this type housing, and how they would benefit:

Short answer

What organization are you referring from? (no self referrals allowed for this program)

I confirm that I am an agency and not self referring.

I confirm