Submission type
Self / household intake
Agency or case manager referral
Government / housing authority
Nonprofit / community organization
Healthcare / social service referral
Other referral source
Full name
Preferred name
Phone number
Email address
Best safe time / method to contact
Desired move-in date
Current city / county
State
ZIP code
Age (optional unless program requires)
Organization / agency
Referrer name
Referrer title / role
Relationship to household
Referrer phone
Referrer email
If there is immediate danger or a medical emergency, call 911. Do not enter sensitive safety narratives or protected shelter addresses here. This form is not monitored.
Household members
Total household size
Adults 18+
Minors under 18
Children under 5
How soon is housing needed?
Today
24–72 hours
Within 7 days
Within 30 days
Flexible
Briefly describe why housing is needed now
Immediate safety concern
No immediate safety concern reported
Staff follow-up requested
Preferred city / county / state — first choice
Second choice
Third choice
Can household relocate out of county?
Can household relocate out of state?
Length of stay needed
30+ day / monthly
3–6 months
6–12 months
12+ months
Flexible
Number of bedrooms requested
Separate sleeping areas needed
Pets / assistance animals
School / work location considerations
Family fit / sleeping arrangement notes
Estimates are acceptable at intake. Final placement may require independent verification. Do not enter bank or card numbers or upload sensitive originals.
Total gross monthly household income ($)
Maximum monthly housing budget ($)
Security deposit / move-in funds available ($)
Utilities / budget notes
Employer / income source details (optional)
Program / voucher type
Issuing agency
Approved monthly amount ($)
Tenant contribution ($)
Expiration / use-by date
Funding status
Caseworker / funding contact
Funding contact phone / email
A diagnosis is not required to request an accommodation. Describe features or support needed only. Referrals depend on partner availability, eligibility, and consent.
Housing feature or accommodation needed
Transportation details / limitations
Additional support or referral request
Other practical placement considerations
PLRK / Safe Haven & Heritage Healing uses completed intake information to evaluate housing needs, communicate about options, coordinate referrals, and support placement. Sharing is limited to what is reasonably necessary with authorized property, agency, funding, and service partners, subject to law and consent. This is not a lease, reservation, benefits determination, or guarantee. Referrals are handled without unlawful discrimination; criteria vary by property and program. Accommodation requests may be raised now or later. Nothing waives legal rights. A typed name records the intended acknowledgment in your copy; this website does not execute or deliver an agreement.
Required acknowledgments — all required
Applicant / head of household typed name
Date
Referrer typed name (if applicable)
Date
Authorized representative / guardian (if applicable)
Date
PLRK coordinates inquiries and referrals as a for-profit business. Rent, deposits, and service fees are governed by separate written agreements. The seventh source page is a financial supplement; extra household rows can be added in part 2.
Applicant legal name
Intake / household ID
Profile date
Gross monthly household income — supplement ($)
Comfortable monthly rent ($)
Available move-in funds ($)
Payer / funding organization
Approved monthly amount — supplement ($)
Resident monthly share ($)
Required deposit / fees ($)
Funding deadline
Voucher / authorization number (when issued)
Authorizing agency / contact
Financial acknowledgment — all required
Financial profile applicant / representative typed name
Date
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