Case manager referral

Submit a Referral

All information is kept confidential. Fields marked * are required.

Website

Referring Organization

Section 1

Referring Organization

Agency name *Referrer name *TitleEmail *Phone *

Prospective Resident

Section 2

Prospective Resident

First name *Last initial *AgeGenderClient phone

Housing Situation & Move‑in Timeline

Section 3

Housing Situation & Move‑in Timeline

Current housing situation

Desired move‑in

Desired Room Type

Section 4

Desired Room Type

Private Shared Either

Monthly Income & Funding Sources

Section 5

Monthly Income & Funding Sources

Approximate monthly income

Funding sources

SSISSDIVA benefitsPension / retirementEmploymentAgency / program fundingPrivate payOther

Care Needs & Safety Screening

Section 6

Care Needs & Safety Screening

Needs supervisionNeeds nursing careNeeds help with personal careSelf‑manages medication

Behavioral / safety notes

Eligibility Checklist & Certification

Section 7

Eligibility Checklist & Certification

Resident is 18 or olderAble to live independently and manage daily self‑careHas verifiable monthly income or fundingWilling to live in a drug & alcohol‑free homeWilling to follow house guidelinesI certify the information provided is accurate to the best of my knowledge and that I have the resident's consent to share it. *

Additional Notes

Section 8

Additional Notes

The Cove at 77

Serving Birmingham, Alabama

Contact

9013200199

thecoveat77@gmail.com

Hours

Monday – Friday, 8am – 5pm

Emergency placement: 6pm – 9pm

Quick links

About
Who We Serve
Pricing & Rooms
Referral Process
Submit a Referral

The Cove at 77 is an independent living residence and does not provide medical or skilled nursing care. We follow Fair Housing principles and do not discriminate on the basis of race, color, religion, sex, national origin, disability, or familial status. Referral information is kept confidential and used only to evaluate placement. © 2026 The Cove at 77.