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REFERRAL FORM

This is a housing program that has been established to assist independent adults. Unfortunately, there is a limited amount of space. If there is no room, applicants will be placed on a wait list.  Each application will get scheduled for an assessment interview after submission. Decisions of who will be accepted into the program are entirely up to GMH.

Gender
Male
Female
Other
How long have you been there?
1 to 5 years
more than 5 years
Have you been diagnosed with Illness?
Yes
No
Do you take medication?
Yes
No
Are you able to take your medication as directed on your own?
Yes
No
Do you have a job?
Yes
No
What are your work hours?
Were you ever locked up?
Yes
No
When were you released?
Month
Day
Year
Are you on parole?
Yes
No
Are you working with any agency?
Yes
No
What type of housing are you looking for?
Emergency
Transition
Long Term (12mo or more)
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Located in the heart of your community, Grace Moore House welcomes referrals from all across the United States. We're proud to accept clients from all over the country.

+1 815 693 5332

info@gracemoorehouse.com

LaSalle County, Illinois

© 2026 GRACE MOORE HOUSE

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This facility does not discriminate in admission, retention and care of residents, because of race, color, creed, national origin, age, gender, marital status, sexual preference, blindness, sponsor, disability or handicap.

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