Restored Home & Safer Space Referral Form

Is this referral for yourself or another person?

Myself Another Person

If for another person, has the client consented to this referral?

Yes No NA

If this is a self-referral, please proceed to the question, "What program are you applying to?"

First Name of Person Referring:

Last Name of Person Referring:

Name of Organization:

Referring Person's Phone:

Referring Person's Email:

What Program are you applying to?

First Name:

Last Name:

Gender:

Date of Birth:

Phone Number:

Alternate Number:

Current Address:

City:

Province:

Postal Code:

Primary Language:

Alternate Contact First Name:

Alternate Contact Last Name:

Alternate Contact Relationship:

Alternate Contact Number:

Program Questions

What range is the client's annual income?

Is the client a homeowner or tenant?

Homeowner Tenant

Number of people residing in home? (relation to client)

Number of bedrooms:

Are there pets? (if yes, how many)

Is there smoking?

Yes No

Are there sharps uncontained?

Yes No

Is there biohazardous waste?

Yes No

Are the facilities working? Appliances and plumbing?

Yes No

Are there infestations? (bedbugs, roaches, mice)

Does the client consent to discarding items?

Yes No

Is client at risk of eviction?

Yes No

Is there a warning letter from the landlord?

Yes No

Are there photos of the unit?

Yes No

Are there clear pathways?

Yes No

Are living spaces accessible and used for their intended use?

Yes No

Can we use the garbage facilities on site?

Yes No

Is there anything else we should know about the situation? (Please provide a brief description)

Please send any applicable documents (photos, warning letters, etc.) to restoredsaferspaces@vha.ca.

For Restored Home Extreme Cleaning Toronto please provide photos and a warning letter from the landlord.

For Restored Home and Safer Spaces: Durham Region please provide a warning letter from the landlord.

If you send photos, please provide clear images of all living spaces.

Referral will be incomplete without the proper documentation.