Home Repair Program Referral

Today's Date *

Date of Referral (if different from today's date)

Referral Source Name *

First

Last

Organization (if applicable)

Title/Role

Phone *

Email

Relationship to Client *

(e.g. family member, social worker, doctor, friend, self-referral, etc.)

Reason for Referral *

Briefly describe the client's need for home repair.

Urgency of Repair *

Urgent (Immediate safety/health hazard)
Moderate (Significant discomfort/inconvenience but not an immediate hazard)
Low (Improvement/non-critical repair)

How did you hear about our program?

If you selected "Other" above, please provide additional information here: *

Use this space to describe how you heard about our program.

Client's Full Name *

First

Last

Date of Birth *

Client's Current Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Where repairs are needed.

Client's Current Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

If different from service address.

Client's Primary Phone Number *

Client's Secondary Phone Number

Client's Email Address

Client's Emergency Contact *

First

Last

Emergency Contact's Relationship to Client

(e.g. family member, social worker, doctor, friend, etc.)

Emergency Contact Phone Number *

Is the client the homeowner *

Yes
No

Is this the client's primary residence? *

Yes
No

Is the client 60 years of age or older? *

Yes
No

Is the client a person with a disability? *

Yes
No

Number of People Living in the Household *

Approximate Household Income (Monthly or Annual) *

This information helps us determine potential for sliding scale/subsidies.

Are there any known financial assistance programs the client is currently receiving or applying for that might cover home repairs? *

Yes
No

(e.g. Medicaid Waiver, VA Benefits, THDA ERP, etc.)

Accessibility Modifications *

Please select all that apply and use the space below to provide a brief description, including location, for each previously-selected item. (copy)

Health and Safety Repairs *

Please select all that apply and use the space below to provide a brief description, including location, for each previously-selected item.

Energy Efficiency/Weatherization *

Please select all that apply and use the space below to provide a brief description, including location, for each previously-selected item.

General/Minor Repairs *

Please select all that apply and use the space below to provide a brief description, including location, for each previously-selected item.

I/we, the undersigned, understand that by submitting this referral, I/we authorize UCHRA to contact the client named in this form to discuss their home repair needs.

Referrer signature

Clear Signature

If the client is NOT completing this referral.

I/We, the client(s) named in this form, authorize UCHRA to assess my/our home repair needs and discuss potential services. I/We understand that this is a fee-for-service program and costs will be discussed before any work is performed.

Client signature

Clear Signature

If client is completing this referral.