AGENCY REFERRAL FORM

for Rapid Re-Housing Services

Clayton, Henry, and Rockdale Counties

If you are someone who is seeking housing assistance, please do not fill out the form on this page. All referrals must go through the Coordinated Entry system.

Please visit the Get Help page to determine your Coordinated Entry point based on your current location.

IF YOU ARE WIITH AN AGENCY AND HAVE SUBMITTED A COORDINATED ENTRY REFERRAL, you only need to fill out the required fields of your name, the client’s name, and the client’s HMIS number. If you have not already entered the client’s phone number in their HMIS profile, please enter it on this form.

Agency Information

AgencyThe name of your agency

Your Name *Your full name

Agency PhonePlease enter without spaces or punctuation

Agency EmailYour email address.

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Client Information

Name *Client's first and last name.

SituationSelect the option that best matches the client's current situation. If in an Institution, stay must be <90 days and must have been literally homeless the night prior to entry. If client's situation does not meet any of the choices, they are not eligible for RRH services.Select OneA place not meant for human habitationEmergency ShelterHotel paid by AgencyInstitution, inc. Hospital, Jail, etc.

DVIs the client currently fleeing or attempting to flee a domestic violence situation?Select OneNoYesUnknown

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Phone(No hyphens)

EmailLeave blank if no email

Referral *In which county is the client currently sleeping?Select OneClayton CountyHenry CountyRockdale CountyGwinnett CountyDouglas County

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IncomeTotal combined gross monthly income for all adult household members. Program income limit is 50% AMI.

HMIS *Veteran's HMIS ID number, if known. If unknown, please complete the "Identifier" field.

IdentifierClient's DoB or last 4. Do not enter the client's full SS number.

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AdultsHow many adults are in the household?

ChildrenHow many childre (under 18) are in the household?

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NotesProvide any details that you need us to know.

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HVLA Homelessness Verification Letter is required prior to the Rapid Re-Housing assessment. Email to the Intake Coordinator or Director is preferable, but you may also use this form to send the HVL. Only PDF, Word, JPG, and PNG files are allowed.

Choose FileNo file chosenDelete uploaded file

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Submit Referral

Please do not fill in this field.