Referral Form

Client Self Statement

Client Consent Form

The packet must be completed in full in order for the referral to be considered. Below, you will find the instructions for the packet and the check list for all documents required to consider it complete.

1. Applicant Self-Statement
   
   1. To be completed by the applicant
2. Referral Form (5 pages)
   
   1. To be completed by the therapist/ counselor/ social worker of the referring agency.
3. Consent for the Release of Confidential Information
   1. Person making the referral, please sign as the witness
   2. Please have applicant initial “accept or reject”. (not a check mark)
4. Letter verifying homeless
   1. To be completed by the referral agency.
5. Letter from psychiatrist documenting mental health diagnosis
   1. To be completed by the mental health provider

To hasten application process, please include (if available):

1. State/Government photo ID of applicant
2. Copies of birth certificates of all members that will be living in the household
3. Copies of social security cards of all members that will be living in the household
4. Copies of insurance cards of all members that will be living in the household
5. The most recent DPW printout (30 days current)

Individuals who inquire on their own behalf will have materials sent to them, but packet completion rests on the provider. All applications will include an Applicant Self-Statement, Referral Form (5 pages), and a Consent for the Release of Confidential Information.

Questions should be directed to Joann English, MOMS Program Manager, at (412) 361-1213 or (412) 335-1116.