Housing Placement Referral Waitlist Form Participant Details Full Name: Date of Birth: Phone Number: Email Address: Preferred Method of Contact: Call Text Email Current Housing Status Unhoused / Unsheltered In transitional or emergency housing Staying with family / friends Currently in a housing program, seeking transfer Brief description of current situation: Referral Preferences Preferred Location / City: Program Type Preferred: Male Female Co-Ed LGBTQ+ Inclusive No preference Shared Housing Comfort Level: Comfortable Prefer private Open to both Desired Timeline for Placement: ASAP Within 2 weeks Flexible Support & Accessibility Needs Any disability accommodations required? Medical or mental health needs relevant to housing? Transportation Access: Own transportation Needs proximity to public transit Background challenges MRS should be aware of (evictions, legal, etc.): Consent & Confirmation I understand that submitting this form places me on the referral waitlist with Madison Rose Solutions and does not guarantee immediate placement. I consent to be contacted by MRS regarding housing placement opportunities. Confirm Full Name: Signature (typed name): Date: Submit Referral Form
