Shelter Plus Care (Home Again) & Supportive Housing (DASH) Application
PLEASE NOTE:
* All applicants must be disabled and currentlyhomeless to qualify.
* Shelter Plus Care (S+C) referring agencies must supply evidence of matching funds quarterly.
*Supportive Housing (DASH) recipients must meet the HUDcriteria forhomelessness orchronichomelessness.
Date of Referral: Completed by:
Referring Agency:
Agency Phone: AgencyFax:
Qualified Professional Phone: Qualified Professional Email:
Eligibility Screening (Check the program the applicant is applying for)
Check all that apply to the applicant:
/ DASH Supportive Housing Program Screening / / Shelter Plus Care Program ScreeningThe household has VI-SPDAT score of 10 or higher AND meets one the following: / The household has VI-SPDAT score of 10 or higher AND meets one the following:
Homeless continuously for at least one year
(i.e., streets, shelter, condemned building) / Homeless continuously for at least one year
(i.e., streets, shelter, condemned building)
Has had at least 4 episodes of homelessness in the past 3 years (i.e., streets, condemned building, etc.) / Has had at least 4 episodes of homelessness in the past 3 years (i.e., streets, condemned building, etc.)
Living in a publicly or privately operated emergency shelter
Living in places not meant for human habitation (i.e., streets, condemned building, etc.)
Living in transitional housing, but came there from places not meant for human habitation OR emergency shelter
Exiting an institution (hospital, jail, etc) where resided for 90 days or less and lived in an emergency shelter or places not meant for human habitation immediately before entering institution
None of the above (household is ineligible for SHP) / Living in a publicly or privately operated emergency shelter
Living in places not meant for human habitation (i.e., streets, condemned building, etc.)
Living in transitional housing, but came there from places not meant for human habitation OR emergency shelter
Exiting an institution (hospital, jail, etc) where resided for 90 days or less and lived in an emergency shelter or places not meant for human habitation immediately before entering institution
None of the above (household is ineligible for S+C)
How long has this person been homeless?
The applicant has been diagnosed with one or more of the following (check all that apply):
Chronic alcohol and/or substance use
Severe mental illness
AIDS or related diseases
Physical or visual disability
None of the above (NOTE: If none of the above, then this person is ineligible.)
This person has been arrested for violentcriminalactivity within the last3years? No Yes*
If yes please explain:
NOTE: The applicant may seek a “reasonable accommodation” if his/her denial is a direct result of the disabling condition identified on the “Verification of Disability” Form (pgs. 7&8).
For Service Providers Only:1. Will the applicant require supportive services after housing is received? / Yes No
2. The referring agency will document the services provided to this voucher recipient on the “Quarterly Reporting Form” and return them quarterly to Housing Coordinator. / Yes No
(*NOTE: If no, then do NOT refer this person )
Referral Information
Name of Agency / QPQP Number / QP Email
Name of Applicant / SS#
Date of Birth / Age
Education / Marital Status
Gender / Male / Female / Veteran Status / N/A / Veteran
Chronic Homelessness (choose one)APR 6-B
This person has been homeless continuously for at least one year (i.e., streets, shelter).
This person has had at least 4 episodes of homelessness in the past 3 years (i.e., streets, shelter).
This person has NOT been homeless continuously for 1 year or at least 4 times in the past 3 years.
Ethnicity (choose one) / APR 7a.Hispanic/Latino / b. Non-Hispanic/Latino
Race (choose one)APR 8
a. American Indian/Alaskan Native / f. American Indian/Alaskan Native White
b. Asian / g. Asian White
c. Black / h. Black White
d. Native Hawaiian/Other Pacific Islander / i. American Indian/Alaskan Native Black
e. White / j. Other Multi-Racial:
Special Needs (check all that apply)APR 9-B
a. Mental Illness / e. Physical Disability
b. Alcohol Abuse / f. Domestic Violence
c. Drug Abuse / g. Other, specify:
d. HIV/AIDS and Related Diseases / g. Other, specify:
Prior Living Situation (check all that apply)APR 10
a. Non-Housing (street, park, bus station, etc.) / g. Jail/prison
b. Emergency Shelter / h. Domestic violence situation
c. Transitional housing for homeless persons / i. Living with relatives/friends
d. Psychiatric facility / j. Rental housing
e. Substance abuse treatment facility / k. Other, specify:
f. Hospital
APPLICANT RESIDENTIAL HISTORY
Alliance Behavioral Healthcare seeks your cooperation in supplying true and accurate information regarding the present and past residential history of the applicant family. Please complete the following Applicant Residential History Form, listing the housing history of the applicant family for the last five (5) years (beginning with the most recent place of residence). This form is to be completed in its entirety; please be sure to list at a minimum, a five year residential history.
HEAD OF HOUSEHOLD NAME:
PRESENT ADDRESS:
Date of Residence: From To
Landlord Name /Name of Mortgage Co.:Telephone:
Monthly Rent/Mortgage:$ Own Rent Other
Reason for Leaving
PREVIOUS ADDRESS:
Date of Residence: From To
Landlord Name /Name of Mortgage Co.:Telephone:
Monthly Rent/Mortgage:$ Own Rent Other
Reason for Leaving
PREVIOUS ADDRESS:
Date of Residence: From To
Landlord Name /Name of Mortgage Co.:Telephone:
Monthly Rent/Mortgage:$ Own Rent Other
Reason for Leaving
Have you ever been evicted from tenancy? Yes No
*If yes, please list date of eviction:
Have you ever received rental assistance or subsidized housing? Yes No
*If yes, was assistance or lease terminated for fraud, failure to recertify, or non-payment of rent/utilities? Yes No
List the names of the people who will be living with the applicantName / Relationship / Age / Hasbirth certificate copy / Has SS# card copy
Yes No / Yes No
Yes No / Yes No
Yes No / Yes No
Yes No / Yes No
Yes No / Yes No
Financial InformationAPR 11-A/C
Complete the chart using the applicant’s estimated monthly income:
Amount / Source of Income per Month$ / SSI (Supplemental Security Income) / a
$ / SSDI (Social Security Disability Income) / b
$ / Social Security Retirement Income / c
$ / Child Support / d
$ / TANF/Work First / e
$ / State Children’s Health Insurance Program (SCHIP) / f
$ / Veteran’s Benefits / g
$ / Employment Income / h
$ / Unemployment Benefits / i
$ / Veterans Health Care / j
$ / Medicaid / k
$ / SNAP (Food Stamps) / l
$ / Other, specify: / m
+ $ / Other, specify: / n
= $ /
TOTAL Estimated Monthly Income
Transitional Plan
What plans are in place to ensure that the applicant will successfully transition from homelessness to independent living (e.g., VR services; employment; life skill training; education; treatment; etc.)?
Service Plan
What services does/will this person receive from your agency or other provider agencies?
Email copy of the completed referral application and required documentation to:
Housing Coordinator
Community Relations Department
Valaria Brown
Authorization for Release of Information
Applicant Name:
/DOB:
/______
Information To Be Released
I hereby authorize the below listed agency(s), facility(s), and/or institution(s) to release any and all information regarding (state specifically what information is being requested or released):
Amount of money spent on care received by a S+C voucher recipient
Diagnostic information (mental health, developmental disability, substance abuse, vision, or physical related)
Care/Disposition/Discharge Plan
Other:
Other:
Names of Agency, Facility and/or Institution
Durham COC US Department of Housing and Urban Development
Durham Housing AuthorityDurham County Department of Social Services
Private Provider (MH/SA/IDD)Administrative Office of the Court
Other:
Other:
Other:
Other:
Signatures
______
Signature of ApplicantDate
______
Signature of Witness Date
Email copy of the completed Authorization for Release of Information to:
Housing Coordinator
Community Relations Department
Valaria Brown
Verification of Disability Form
Applicant Name:
/______
/DOB:
/______
This person has applied for housing assistance under a program of the US Department of Housing and Urban Development (HUD), which requires the verification of all information that is used in determining this person’s eligibility or level of benefits. Please complete the sections below.
Authorization for Release of Information
I hereby authorize the below listed agency(s), facility(s), and/or institution(s) to release any and all information regarding (state specifically what information is being requested or released):
Diagnostic information (mental health, developmental disability, substance abuse, or physical related)
Other:
Names of Agency, Facility and/or Institution
Durham COC US Department of Housing and Urban Development
Durham Housing AuthorityDurham County Department of Social Services
Private Provider (MH/SA/IDD) Administrative Office of the Court
Other:
Other:
Signature of Applicant Authorizing Release and Witness
______
Signature of ApplicantDate
______
Signature of Witness Date
Penalties for misusing the consent: Title 18, Section 1001 of the US Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the US Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willing requests, obtains, or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 42 USC 208(f)(g) and (h). Violations of these provisions are cited as violations of 42 USC 208(f)(g) and (h).
Email copy of the completed Verification of Disability Form to:
Housing Coordinator
Community Relations Department
Valaria Brown
Applicant Name:
/DOB:
Directions: Place an X in the appropriate box for each disability section or choose “Not applicable.”
Section 1. Visual Disabilities / Not applicableHas a disability as defined in 42 U.S.C., which means:
Inability to engage in any substantial gainful activity be reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months; or
In the case of an individual who has attained the age of 55 and is blind, inability by reason of such blindness to engage in substantial gainful activity requiring skills or abilities comparable to those of any gainful activity in which he/she has previously engaged with some regularity and over a substantial period of time.
(For the purposes of this definition, the term blindness, as defined in section 416(i)(1) of this title, means central vision acuity of 20/200 or less in the better eye with use of a correcting lens. An eye that is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for the purposes of this paragraph as having a central visual acuity of 20/200 or less.)
Section 2. Physical, Mental, Emotional Disabilities / Not applicableHas a physical, mental, or emotional impairment that:
Is expected to be of long-continued and indefinite duration;
Substantially impedes his or her ability to live independently; and
Is of such a nature that the ability to live independently could be improved by more suitable housing conditions.
Section 3. Developmental Disabilities / Not applicableHas a developmental disability as defined in Section 102(7) of the Developmental Disabilities Assistance and Bill of Rights 42 U.S.C. 6001(8), i.e. a person with severe chronic disability that:
Is attributable to a mental or physical impairment or combination of mental and physical impairments;
Is manifested before the person attains age 22;
Is likely to continue indefinitely;
Results in substantial functional limitation in three or more of the following areas of major life activity: a) self-care, b) receptive and expressive language, c) learning, mobility, d) self-direction, e) capacity for independent living, and f) economic self-sufficiency, and
Reflects the person’s need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated.
Section 4. Substance Dependence / Not applicableIs this person’s disability based on alcohol and/or drug dependence?
Contact Information and Signatures of Qualified Professional Completing Form
IMPORTANT! – Written documentation MUST come from a medicaldoctor, psychiatrist, psychologist,LPC, LCSW, or Nurse Practitioner trained to make determinations. A case manager or qualified professional does NOT qualify.
Agency Name Telephone
AddressCityZip Code
______
Print Name & Title Signature Date
Service Provider Agreement
PLEASE NOTE: The issuing agency may terminate the Supportive Housing subsidy of any recipient who fails to comply with requirements of the program.
PLEASE NOTE: For your client to receive Supportive Housing, the recipientis strongly encouraged to engage in support services during the recipient’s time in the Supportive Housing programto help them maintain their housing and assist them with their behavioral health and/or physical health recovery process.
The referring agency agrees to provide Alliance Behavioral Healthcarethe necessary documentation to complete all US Department of Housing and Urban Development, NC Department of Health and Human Services, and NC Division of Mental Health, Developmental Disabilities, And Substance Abuse reports and to maintain the integrity of the Shelter Plus Care and/or Supportive Housing Programs.
This documentation includes:
- Changes to the client’s service providers that might impact matching fund documentation
- Changes to the services provided to the client that might impact matching fund documentation
- Changes to the treatment plan that might impact matching fund documentation
- Changes to the client’s assigned caseworker and contact information
- Changes to the client’s income or employment that might impact the client’s rent subsidy
- Changes to the number of persons living in the household
In addition, the referring agency agrees to provide any additional information needed for reporting purposes or to maintain the integrity of the Shelter Plus Care and/or Supportive Housing Programs.
The referring agency agrees to complete the Quarterly Report by the 15th of the specified month. The Quarterly Report will be sent quarterly to the Community Relations Specialist for Housing.
The referring agency understands that failure to provide the necessary documentation to complete all mandated reports might result in the loss of the client’s voucher and impact the referring agencies ability to refer applicants in the future.
Signatures
I have read & understand the above agreement.
______
Signature of Referring AgentName of Referring AgencyDate
Recipient Agreement
PLEASE NOTE: To receive a Shelter Plus Care OR Supportive Housing Voucher, it strongly encouraged you receive support services during you time in the program to help you maintain your housing and assist you with your behavioral health and/or physical health recovery process.
PLEASE NOTE: The issuing agency may terminate anyone who does not comply with lease, does not comply with program requirements, engage in illegal/unlawful activity, fail to notify of changes in household composition or income.
This agreement is set forth on ____/____/___ between Alliance Behavioral Healthcare & (tenant name) ______, hereafter referred to as tenant.
The tenant agrees to report to Alliance Behavioral Healthcare any & all changes that are required to maintain the integrity of the Shelter Plus Care or Supportive Housing program.
The tenant is responsible for reporting any change in supportive services or the tenant’s supportive service provider in writing within 10 days of the change.
The tenant understands that the Shelter Plus Care and Supportive Housing Programs strongly encourages the tenant to utilize supportive services at all times in order to help them maintain their housing.
Should the tenant not comply with all of the requirements of the Shelter Plus Care or Supportive Housing Program, the tenant’s voucher assistance will be terminated with a 30-day notice. This means Alliance Behavioral Healthcare/Durham Housing Authority will no longer fund (i.e., pay rent, utility payments, etc.) on the tenant’s behalf.
The tenant agrees to make application and accept a Housing Choice Voucher (Section 8) or Public Housing Voucher as they become available.
Signatures
I have read & understand the above agreement.
______
Signature of TenantDate
______
Signature of Alliance Behavioral Healthcare Housing CoordinatorDate
Required Documentation*– Submit all documentation with application!
Check the documentation that has been attached to this referral form:
Documentation of Disability – See the “Verification of Disability Form” (pages 7-8 of application)
Verification of Homelessness – See the “Documentation of Homelessness Guide” for a list of the requireddocumentation to verify homelessness (page 12 of application)
Proof of financial resources for every adult who will be living with the voucher recipient
Birth certificates (or equivalent) for every person who will be living with the voucher recipient
Social Security cards for every person in who will be living with the voucher recipient
A current address/phone number where the person can be reached when a voucher is issued
A Criminal Background Check for each adult living in the household
(*Note: Do NOT submit application WITHOUT required documentation!)
Documentation of Homelessness Guide
Persons served by this program should be homeless according to the following definition used by the Continuum of Care (COC) Program. Please check the appropriate box that applies to the applicant family.
A person is homeless if he/she:
□Is an individual or family who lacks a fixed, regular, and adequate nighttime residence or an individual who is exiting an institution where he or she resided for 90 days or less and who resided in an emergency shelter or a place not meant for human habitation immediately before entering that institution; or