Refer a Client / Intake Form

IM HER Independent Living partners with agencies, case managers, and community professionals to provide a structured independent living environment in a supportive home setting. Our program focuses on stability, accountability, and respectful community living.

To begin the referral process, please submit the referral form below. Our team will review and follow up regarding next steps and availability.

Contact Us

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Personal Information

First Name

Last Name

Email Address

Phone Number

City

State

Date of Birth

Current Residency

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Residency History

Last 3 Years of Residency (Optional)

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Referral Source

How did you hear about our program?

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Employment & Income

Are you currently working?

Yes

No

Where have you worked in the past 12 months?

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Monthly Income (current)

Do you have a bank account?

Yes

No

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Housing Needs

What type of housing placement are you seeking?

Emergency Placement (24–72 hours)

Short‑Term Housing (1–4 weeks)

Long‑Term Placement

Re‑Entry Housing

Transition from Shelter or Hospital

Other

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Background & Risk Screening

Do you have a history of any of the following?

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Support Needs Assessment

Do you need assistance with any of the following?

Job placement

Mental health services

Substance recovery

Life skills / budgeting

Transportation

None

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Additional Information

Are you a veteran?

Yes

No

Do you have any pets?

Yes

No

Room Preference

Shared room (starting at $650)

Private room (if available)

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Emergency Contact

Emergency Contact Name

Relationship

Phone Number

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Document Uploads

Government‑issued Photo ID

Upload file

Proof of Income

Upload file

Referral Documentation

Upload file

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Program Agreement

Please review and acknowledge:

I understand this is a structured independent living program

I agree to follow all house rules and program guidelines

I understand that program and administrative fees are non‑refundable

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Interview Scheduling

Interview Date

Interview Time