Miracle Houses Inc Referral Application. To make a referral, please complete the form below.Items marked with (*) are mandatory.For questions, please call or email Miracle Houses Inc. Referral FromReferring AgencyReferral InformationReferral NameReferral Title: Referral PhoneBest time to callReferral AddressConsumer InformationFirst NameLast NameDOBAgeSSNPhoneMaterial StatusSingleMarriedWidowedSeparatedDivorcedRaceGenderMaleFemaleOtherAddressCurrent LocationSchoolConsumer GuardianPhoneConsumer Health InformationMedicaidInsuranceMedication DosageDiagnosisConsumer Reason For AdmissionProgram DesiredReferral Source: Guardian CM SW DJJReferral to Another Provider Yes NoPsychosocial Yes NoList of AttachmentsChoose File Submit Form “Where Miracles Happen”