Refer a Resident

FORMS & DOCUMENTS

Submit a Resident Referral

Submit a referral online below or download the fillable intake packet. Soft referrals are welcome if some information is not available yet.

Serving San Bernardino, Riverside & Los Angeles Counties

Shared and private rooms availableRates vary by location, county, room type, and availability. Contact us for current pricing.

Prefer a downloadable form? Complete the six-page fillable PDF, save your answers, and return it to SHS. If your browser does not save answers, open it in Adobe Acrobat Reader.

Prospective Resident Information
Population Category (check all that apply)
Can the individual live independently and manage daily activities without assistance? *
Are there any known safety concerns that may impact placement? *
Desired Move-In Timeframe *
Referral Source Information
Supporting Document