Est. 1972
Serving DC, MD and VA
2410 17th St., N.W. • Suite 100 • Adams Alley • Washington, D.C. 20009
202-667-7006 • www.housingetc.org
Referring Worker Email
Referring
Worker
Telephon
e
Number:
SUPPORTIVE SERVICES FOR VETERAN
FAMILIES (SSVF)
REFERRAL FORM
TO BE COMPLETED BY REFERRING WORKER (PLEASE PRINT)
Housing Counseling Services (HCS) Supportive Services to Veteran Families (SSVF) Program
provides case management and supportive services to very low income Veteran families in the D.C.
metropolitan region who are homeless or at risk for homelessness towards stabilizing their housing
situation through permanent housing. Veteran households accepted in the HCS SSVF Program
may be eligible for financial assistance, housing counseling, and assistance accessing Veteran
Benefits and other entitlements.
After completing this referral form, please submit to HCS via fax at (202)-667-0862 or via
email at [email protected]. For additional information regarding the HCS SSVF
Program please contact HCS at (202) 667-7006.
Today’s Date
Referring Agency:
Referring Worker Name:
:
CLIENT NAME: ________________________________________________________ PHONE: ____________________________
ADDRESS: __________________________________________________________________________ APT #: ________________
CITY: _________________________________________________________________ STATE: _____________________________
ZIP: __________________
COUNTY: ________________________________________________________________________
EMAIL:_______________________________________________________________
NUMBER OF PEOPLE IN HOUSEHOLD: __________ MONTHLY HOUSEHOLD INCOME: $______________________________
MILITARY VETERAN?
 YES  NO
BRANCH: _____________________AFGHANISTAN/IRAQ VETERAN ___YES ___NO
HAS CLIENT RECEIVED SERVICES THROUGH ANY SSVF PROGRAM BEFORE?
 YES  NO
If Yes, which organization? ________________________________________________ Date Served (Month/Year): __ __ / __ __
CLIENT’S CURRENT HOUSING STATUS:
 Currently Homeless
 At Risk for Homelessness
 No Immediate Risk of Homelessness
REASON FOR REFERRAL (print clearly):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Last updated 2/24/14