Housing Referral Form

Member information

Reason for referral (Please include housing request, reason for referral and current living situation)

Member name

Parent/guardian name (if member is a child)

Last known address

County of last known address

Member phone

Permission to call/text member/member representative?

Yes No

Member email

Permission to email member/member representative?

Yes No

If the member is a child, are they on the same plan as the parent/guardian

Yes No Unsure

BadgerCare or Individual and Family Plan Member ID #

Casehead/Parent/Guardian ID #

GuidingCare ID #

Number in Household

Number of children in the household

Is the member/member representative aware of the referral?

Yes No Unsure

Clinical history

Diagnosis (Medical and Behavioral Health)

Utilization history (within the last 12 months)

List of needs/concerns (if known)

In the past 12 months has the member and/or their children not had enough money to pay any of the following? (Select all that apply)

Mortgage Rent Utilities

Have the member and/or their children experienced either the following? (Check all that apply)

Homelessness Living in a shelter

Have any of the following contributed to housing instability? (Check all that apply)

Employment Income Eviction history Rental references Language barrier Other

Other contributions to housing instability

Resources provided/community program involvement (Check all that apply)

Social Development Commission (SDC) Community advocates Children’s Community Services Housing voucher Other

Other resources provided/program involvement

Other factors/barriers

High risk pregnancy Domestic abuse Unsafe living conditions Chronic/physical condition Hospital readmissions Behavioral health Substance use Language Additional factors/barriers

Additional factors/barriers

Referral Source Information

Name

Phone

Email

Relationship to client (case manager/social worker/etc.)

Referring agency/program name

Additional information

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For any questions contact Chorus Community Health Plans at (414) 266-3173 or email us.

Member information

Clinical history

List of needs/concerns (if known)

Referral Source Information