Transfer - Stabilization (PSH)

LAFH LOCATION

Transfer Request - (PSH)

Stabilization (PSH), this form is used when transferring to LAFH PSH Stabilization. Common transfers are the following: SPA 2 Welcome Home Project, WH-COC 90-LAFH, LACDA D7, DHS/ICMS connected participants to specific properties

Please take care to complete EACH field with the correct information.

Case manager's first name

Case manager's last name

Case Manager's Information

Case manager's email

Case manager's phone

Participant's Information

HMIS ID

Program

Funding source

Participant's phone number

Participant's alternate phone

Participant's email

Number of adults in household

Number of children in household

Primary language

VI SPDAT Score

Full SPDAT Score

Participant's first name

Participant's last name

Barriers:

Goals:

Medical/Mental Health Needs:

Landlord's Contact Information

Landlord's first name

Landlord's phone

Landlord's last name

Landlord's email

House number

Street name

City

Unit type

Apartment or house?

Unit number

ZIP code

Security Deposit

Monthly rent

Anticipated move-in date

Date PO submitted

Other providers involved:

Date furniture PO?

Vendor

.pdf, .doc, .xls

Upload File

.pdf, .doc, .xls

Upload File

Your transfer request for PSH has been submitted.