Make a Referral to MOMS

We appreciate your interest in our permanent housing program, Sojourner House MOMS. You will find all the forms you need to complete an application packet for you and your participant at the links below. 

• 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
To be completed by the applicant 

2. Referral Form (5 pages)
To be completed by the therapist, counselor or social worker of the referring agency. 

3. Consent for the Release of Confidential Information
Person making the referral, please sign as the witness.
Please have applicant initial “accept or reject” (not a check mark). 

4. Letter verifying homeless
To be completed by the referral agency. 

5. Letter from psychiatrist documenting mental health diagnosis
To be completed by the mental health provider 

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

• State/Government photo ID of applicant
• Copies of birth certificates of all members that will be living in the household 
• Copies of social security cards of all members that will be living in the household 
• Copies of insurance cards of all members that will be living in the household 
• 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.