Referral Information

Full Name

Phone Number

Email Address

Relationship to the Applicant

Organization / Agency (If Applicable)

Job Title (If Applicable)

Applicant's Full Name

Phone Number

Email Address (If Available)

Date of Birth or Age

Current City & State

Is the applicant aware this referral is being made?

Yes No

Has the applicant agreed to be contacted by JP Stability Homes?

Yes No

Reason for Referral

How long have you known the applicant?

What services or support is the applicant currently receiving? (If Applicable)

Is the applicant currently experiencing any of the following? (Check all that apply)

Does the applicant currently have a source of income?

Yes No Unsure

Is the applicant willing to follow house rules and program expectations?

Yes No Unsure

Can the applicant live independently with minimal assistance?

Yes No Unsure

Does the applicant have any accommodations or support needs JP Stability Homes should be aware of?

Based on your professional knowledge or involvement with the applicant, do you believe the applicant can safely participate in a structured shared living environment?

Yes No Unsure

To the best of your knowledge, has the applicant received a behavioral health, mental health, or substance use evaluation?

Yes No Unsure

To the best of your knowledge, does the applicant present an immediate safety risk to themselves or others?

Yes No Unsure

Are there any behavioral, medical, or support needs JP Stability Homes should be aware of?

Will you or your organization continue providing services or case management after placement?

Yes No Not Applicable

If concerns arise regarding the participant's participation or safety, may JP Stability Homes contact you?

Yes No

If the participant is unable to remain in the program, are you or your organization willing to assist with identifying alternative resources or placement?

Yes No Not Applicable

Best Phone Number for Follow-up:

Best Email for Follow-up:

Is this an emergency or urgent housing referral?

Yes No

When does the applicant need housing?

Within 24 Hours Within 48 Hours Within 7 Days Other:

If JP Stability Homes is unable to accommodate this referral immediately, may the applicant be placed on our waiting list?

Yes No

Who will be responsible for the participant's participation fees?

Agency/Organization Name (If Applicable):

Contact Person

Phone Number:

Email Address:

Additional Comments

Supporting Documents (Optional)

Upload Files:

I certify that the information provided in this referral is true and accurate to the best of my knowledge.

I understand that submitting a referral does not guarantee acceptance or placement in JP Stability Homes.

I understand that all referrals are reviewed based on eligibility, program requirements, safety considerations, compatibility with the shared living environment, and bed availability.

I understand that the applicant must successfully complete the screening and admission process before being accepted into the program.

I understand that payment by an agency, organization, family member, government program, or other third party does not guarantee admission or continued participation in the program.

I understand that the JP Stability Homes Community Fee is non-refundable.

I understand that once a participant has moved into the program or their participation period has begun, participation fees are generally non-refundable and will not be prorated, regardless of voluntary departure, discharge, removal, hospitalization, incarceration, or any other reason.

I understand that JP Stability Homes reserves the right, at its sole discretion, to issue a refund, partial refund, credit, or other accommodation under extraordinary circumstances. Any exception must be approved in writing by management and does not establish a precedent for future requests.

I understand that all participants are expected to comply with the JP Stability Homes policies, procedures, and program requirements throughout their stay.

I understand that if I am a professional referral source, JP Stability Homes may contact me for additional information regarding this referral, where permitted by law and any required consent.

I have read, understand, and agree to the statements above.

I understand that requesting an emergency placement does not guarantee immediate or permanent admission. Emergency referrals are subject to the same eligibility requirements, screening process, policies, procedures, program rules, safety considerations, compatibility with the shared living environment, and bed availability as all other referrals. If accepted on an emergency basis, continued participation is contingent upon ongoing compliance with all JP Stability Homes policies, procedures, program requirements, and expectations.

Printed Name of Referrer *

Organization/Agency (If Applicable)

Date

By checking this box and submitting this form, I acknowledge that my typed name serves as my electronic signature and that the information provided in this referral is true and accurate to the best of my knowledge. I understand and agree to the acknowledgments and terms contained within this referral form.

(704)-448-5035

info@jpstabilityhomes.com

Cabarrus County & Mecklenburg County of North Carolina

Refer an Individual to JP Stability Homes

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Contact Information

(704)-448-5035

info@jpstabilityhomes.com

Cabarrus County & Mecklenburg County of North Carolina