Housing Placement Referral Waitlist Form Participant Details Name * First Name Last Name Date of Birth * MM DD YYYY Phone (###) ### #### Email * Preferred Method of Contact: * Call Text Email Current Housing Status 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: * First Name Last Name Signature (typed name): * Date * MM DD YYYY Thank you!
