Mi Casa Referral Form

ELIGIBILITY 

To enter the program the student must: 

• Not have an infection requiring isolation (Active TB or COVID-19). Negative Tests prior to entry. • Be physically independent and capable of self-care and can walk up a flight of stairs 

• Understand and able to follow rules/behavioral guidelines, including the personal property rule (2 bags), no visitor policy, and no drug or alcohol use
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Client's Name *
Client Phone Number *
Referral Date *
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If in Custody, Estimated TX Date
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Referrer's Name *
Referrer's Organization *
Referrer's Phone Number *
Referrer's Email *
Is your Client Justice Involved? *
Case Manager's Name *
Case Manager's Phone Number *
Supervision Type *
SF #: *
CDCR #: *
BOP #: *
Has your client ever been required to register as a sex offender under section 290 of the California Penal Code? 
 *
Supervision End Date *
MM
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DD
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YYYY
Is your client homeless? *
Is your client currently using drugs? *
If yes, what are they using:
Does your client have a history of substance abuse? *
Has your client completed residential treatment?
 *
Is your client on Medication Assisted Treatment (MAT)?
 *
If yes, what kind of MAT?
Does your client have a history of mental illness? *
Is your client taking medication for a diagnosed mental illness?
 *
If yes, what is the medication?
What is their current diagnosis?
Any other additional information related to client that would be helpful for the program to know:
What is 1 + 4? (For Captcha purposes) *
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