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Divine Mercy Village Referral Form

For professionals — hospitals, treatment centers, veterans organizations, social workers, case managers — referring a client on their behalf.

Use this form to refer a client to Divine Mercy Village. Please confirm the client has consented to this referral before submitting. Our team will respond within 1-2 business days.

Referring Party Information

Your name

*

Organization / agency name

*

Your role/title

*

Phone number

*

Email address

*

Client Information

Client's full name

*

Client's date of birth

*

Client's phone number

*

Has the client consented to this referral and to Divine Mercy Village contacting them?

*

A

Yes

B

No

Referral Details

Which program is this referral for?

*

A

Recovery Housing

B

Veteran Housing

C

Not sure — please advise

Briefly describe the client's current situation and housing need

*

What is the urgency of this referral?

*

A

Immediate/emergency

B

Within 2 weeks

C

Within a month

D

Exploratory

Is the client currently in a facility, program, or institution with a discharge date? If so, when?

*

Relevant Background

Any known safety considerations we should be aware of before intake?

*

A

Yes

B

No

Is this referral connected to a court order, treatment mandate, or discharge plan?

*

Any supporting documentation available to share?

*

Size limit: 10 MB

Follow-Up

Best way and time to reach the client

*

Anything else we should know before reaching out?

*