My Vineyard Columbus - Transitions Agent Referral Application

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We are excited to partner with agencies in our community serving this vulnerable population.

Individuals must be referred by an agency and or case worker. Below is the list of eligibility requirements:

Transitioned into stable housing in the last 90 days
Income below 200% of Federal Poverty Guidelines
Completed Transitions Application Form

Referring Agency Information

Agency Name

Agency Name is Required

Agency Contact Name

Agency Contact Name is Required

Agency Contact Email

Agency Contact Email must be a properly formatted EmailAgency Contact Email is Required

Agency Contact Phone

Agency Contact Phone is Required

Date of Referral

Date of Referral is Required

Static HTML Content

Applicant Information

* Denotes a Required Field

* First Name

* First Name is Required

* Last Name

* Last Name is Required

Cell Phone

* Address

Street Address is required

City is required

State is required

Zip Code is required

* Birth Date

* Birth Date is RequiredInvalid Date

* Move-In Date (Actual/Estimate)

* Move-In Date (Actual/Estimate) is Required

Country of Origin

Primary Language

US Military Veteran

* Number of FEMALE Adults in Household

* Number of FEMALE Adults in Household is Required

* Number of MALE Adults in Household

* Number of MALE Adults in Household is Required

Number of FEMALE Children in Household

Age(s) of Female Children

Number of MALE Children in Household

Age(s) of Male Children

Circumstances and relevant date surrounding recent transition to permanent housing

Refugee Resettlement

YesNoRefugee Resettlement is Required

Resettlement Date

Period of Homelessness

YesNoPeriod of Homelessness is Required

Homelessness Start Date

Homelessness End Date

Domestic Violence

YesNoDomestic Violence is Required

Event Date

Period of Incarceration

YesNoPeriod of Incarceration is Required

Incarceration End Date

Human Trafficking

YesNoHuman Trafficking is Required

Trafficking End Date

Other

Household Items Request List

After consulting with client(s) regarding household needs, please develop the list of items needed and quantity requested. Item quantities are limited to the number of individuals living in the home and subject to availability. ** For all items, please note requested quantities. Some items may have limited quantities available.

Bedroom Items (All bedding is new)

Sets of Sheets:

Twin Sheet

Full Sheet

Queen Sheet

King Sheet

Blankets:

Twin Blanket

Full Blanket

Queen Blanket

King Blanket

Pillows (One per Person):

Bathroom Items

Bath Towels & Wash Cloths:

Other Items

Shower curtain / shower liner / hooks (1 set per household)
Toiletry kit (1 per household - soap / shampoo / toothbrush / toothpaste)
Toilet plunger
Toilet brush

Note: We are no longer able to supply kitchen items.

If approved, your case worker will be notified when the set is ready for pick-up.

For Office Use Only

Date Reviewed

Reviewer

Review with referring Agent

YesNo

Referring Agent Notes

Review with Applicant

YesNo

Applicant Notes

Approved

YesNo

Result

FullPartial

Pick-up / Delivery Date

Exchange Assigned

Notes

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6000 Cooper Road
Westerville, Ohio 43081
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