HARMONY BEGINNINGS
LLC | INDEPENDENT SHARED LIVING
REFERRAL FORM
(313) 650-2558 | admin@harmonybeginnings.org | Detroit, MI
Agency / Organization
Referring Professional
Phone Number
Email Address
Relationship to Applicant
Date of Referral
Applicant Full Name
Date of Birth
Phone Number
Email Address
Current Address / Location
Preferred Move-In Date
Primary income / benefits (check all that apply):
□ SSI □ SSDI □ Pension □ VA Benefits □ Employment □ Other: ____________________
Current housing situation:
□ Unhoused □ Shelter □ Transitional Housing □ With Family/Friends □ Other: ______________
Approx. Monthly Income / Benefits
Government / Benefit Program (if applicable)
Reason for referral / housing needs:
Please check any that apply:
□ Seeking a drug- and alcohol-free living environment
□ Able to live independently
□ Willing to follow structured house rules / quiet hours
□ Interested in employment or community resources
□ Needs resource connections / supportive services
Emergency Contact Name / Relationship
Emergency Contact Phone
I authorize the referring professional/agency listed above to share information reasonably necessary for Harmony Beginnings LLC to review this housing referral and coordinate placement. Submission of this form does not guarantee acceptance or housing availability.
Applicant Signature
Date
WHO WE SERVE
Veterans · Seniors · Re-entry individuals · Individuals receiving SSI/SSD · Pension & Government benefit recipients
HOUSING FEATURES
Furnished shared rooms · Utilities included · Free WiFi · Onsite laundry · Structured house rules · No credit checks
A FRESH START. A BETTER TOMORROW.