For referring professionals

Referral & Placement Inquiry

Share basic information for a future placement conversation. The pilot home is still in development, so this is not an application for immediate placement or emergency housing.

Keep sensitive records off this form.Do not include medical information, diagnoses, medication details, therapy records, safety plans, case numbers, or court records. A reference number will appear after a successful submission.

01 Referring professional

Full nameProfessional titleOrganization or agencyRelationship to young adultProfessional emailDirect phone number

02 Young adult and placement need

Use the young adult’s preferred first name and last initial. Do not enter a Social Security number, full birth date, medical records, court documents, or identification numbers.

Preferred first name and last initialAgePronouns (optional)County or service areaFoster-care or transition statusCurrent living situationFuture planning timelineCurrent planning stagePrimary reason for referral

This is a planning inquiry, not an active placement application. If anyone is in immediate danger, call 911. For urgent local resources, contact 211 Texas.

03 Initial placement screening

Provide only general planning information. Do not include diagnoses, medication information, medical or therapy records, safety plans, case numbers, or court records.

Education or employment statusIncome or benefits statusIndependent-living strengths and skillsYoung adult’s goals for placement

04 Consent and acknowledgment

I confirm the young adult knows about and consents to this referral.I confirm the information is accurate to the best of my professional knowledge.I understand this form is for initial placement review, does not guarantee acceptance, and must not include highly sensitive records or emergency information.

By submitting, you agree that Haven of Their Rise may use this information solely to review and respond to the placement request. See our privacy notice.