YWCA Missoula
1130 W. Broadway
Missoula, MT 59802
T: 406-543-6691
F: 406-543-6777
Ada’s Place Rapid Re-Housing
Family Application
It is the YWCA of Missoula's policy to not discriminate against any persons based on race, physical or mental disability, religion, national origin, sex, age, creed, physical condition, sexual orientation, gender identity, or expression.
The YWCA Ada’s Place Rapid Re-Housing Program is a housing program designed to assist homeless families in establishing or regaining overall self-sufficiency and housing stability through housing search, rental assistance, and intensive case management. For this program, a family is defined as a group of individuals with one or more parent or primary caregiver who has one or more children under the age of eighteen in their custody.
Eligibility Requirements:
Y □ N □ The family must be homeless to qualify for services; (by HUD’S definition, a homeless family is: one that is forced to spend the night in a place not meant for human habitation, in an emergency shelter, having been discharged from an institution with a lack of resources and the support network needed to obtain access to housing, or fleeing from domestic violence.
Y □ N □ The family must have children, under the age of 18, living with them at least 50% of the time.
Y □ N □ The family must be willing to commit to the program prior to finding stable housing.
Y □ N □ The family will be required to meet with a case manager on a monthly basis for re-certification.
Y □ N □ The family must demonstrate that they are willing to take necessary steps required in reaching self-sufficiency and housing stability.
Non-Eligible Circumstances:
Ø Families who are currently housed.
Ø Families who do not have children living with them at least 50% of the time.
Ø Families who are staying with relatives or friends long-term.
Ø Families not willing to follow through with the goals developed with the case manager.
I have read and understand the eligibility requirements. I am willing to participate in the program.
______
Adult One Signature Date
______
Adult Two Signature Date
______
Rapid Re Housing Program Staff Signature Date
HOUSEHOLD INFORMATION:
Name of Head of Household (HoHH): ______
Address (Where you live now): ______
City, State, ZIP: ______
Phone: ______Alternate Contact: ______
List the Head of Household and all other members who will be living in the unit. List adult members first.
Members Full Name / Relationship to HoHH / Birthdate / Age / Sex1 / Head of Household
2
3
4
5
6
Are you or your spouse currently pregnant?
□ Yes □ No
Due Date: ______
Have you or anyone in your family ever experienced domestic violence?
□ Yes □ No
Have you or anyone in your family ever experienced sexual assault?
□ Yes □ No
Are you or your spouse a registered sexual or violent offender?
□ Yes □ No
INCOME INFORMATION:
What is the total monthly income for the household? $______/Month
Income Source / Monthly IncomeAmount / Name of Family Member(s)
receiving income
Earned Income (i.e. employment income)
Unemployment Insurance
Supplemental Security Income (SSI)
Social Security Disability Income (SSDI)
Veteran's disability payment
Private disability insurance
Worker’s compensation
Temporary Assistance for Needy Families (TANF)
Retirement income from Social Security
Veteran’s pension
Pension from a former job
Child support
Alimony or other spousal support
Other source: ______
Monthly Expenses / Monthly
Amount / Details
Mortgage/Rent
Insurance
Electricity
Water
Phone
Cable
Groceries/Food
Gas/Fuel
Child Care
Credit Card/Debt payments
Clothing
Other
HOUSING INFORMATION:
Where did you sleep last night? (check one)
□ Place not meant for habitation (car, camping, etc.)
□ Emergency shelter (Shelter name: ______)
□ Hotel (Who paid for hotel: ______)
□ Friend or family member’s home
□ Transitional Housing (Program name: ______)
□ Hospital □ Jail/Prison □ Rental (Property name: ______)
How long have you been living/sleeping there? (check one)
□ One week or less □ More than three months, less than one year
□ More than one week, less than one month □ One year or longer
□ One to three months
Background Check Release
All adults are required to have a background check. The YWCA is unable to provide lodging for registered sexual and violent offenders. By signing this form I hereby allow YWCA Missoula to complete the background check for violent and sexual offenses.
Adult One Printed name (First, Middle, Last)
Adult One Signature Date
Adult Two Printed name (First, Middle, Last)
Adult Two Signature Date
______
Certification of Homeless Status
I am currently (please only check one):
□ Living on the street (such as cars, parks, sidewalks, abandoned buildings).
□ Living in an emergency or domestic violence shelter.
Shelter name Discharge date
□ Fleeing domestic violence within the past 30 days.
Under penalty of perjury, I certify that the information presented in this certification is true and correct to the best of my knowledge. I understand that providing false statements constitutes an act of fraud. False, misleading or incomplete information may result in the denial or termination of housing assistance. The information provided will remain confidential and be used only to verify program eligibility.
Adult One Signature Date
Adult Two Signature Date
Rapid Re-Housing Staff Signature Date
Rental Reference Information
Please provide 2 rental references.
Property Manager: ______Phone: ______
Address: ______Apartment Number: ______
City: ______State: ______
When did you rent from them? ______
Property Manager: ______Phone: ______
Address: ______Apartment Number: ______
City: ______State: ______
When did you rent from them? ______
Applicant Statement
My signature below certifies that all information on this application is true, correct, and complete to the best of my knowledge, and contains no willful falsifications or misrepresentations. I authorize the YWCA to contact my present and past employers and the references listed above to obtain information deemed appropriate to consider my application for the Transitional Housing program.
Applicant Signature ______Date ______
CHRIS Client Information Sheet and Release for Data Entry
This form is optional and will not affect your placement in Emergency Housing
WHAT IS CHRIS?
The CHRIS is a computerized record keeping system that contains information about people
experiencing homelessness and people at risk of losing their housing. It includes information about their service needs. Partner agencies in the CHRIS project collect information about the clients they serve and the services they provide. This information is collected and stored in a central database and only partner agencies have access to this information.
WHY COLLECTING INFORMATION ABOUT YOU IS BENEFICIAL?
· Collecting information about people experiencing homelessness is essential to the provision of services because:
· It cuts down on the amount of information you have to share at each agencies if you are seeking multiple services.
· It will eliminate additional intake interviews at each agency.
· It helps communities compete for federal funds, receive funding and ensures future funding for services.
· It helps service providers identify and plan for services that are needed that are not currently available.
· It speeds access to and information about local availability of services.
· It improves coordination of services.
By signing this document you:
· Acknowledge that demographic information about you and your family will be entered into the CHRIS database at 2-1-1.
· Allow basic demographic information about you/your family to be viewed by other service providers that are assisting you and your family.
· Understand that no information such as health, medical needs, mental health and/or domestic violence will be shared without your specific written approval.
You can choose to have any information that you have shared deleted from the system at any time as well as request a document containing information about who has updated your client information. The information that you provide, combined with that provided by others, will be used without identifying information for reporting requirements and advocacy.
______
Client’s Signature Other Party
(If client is minor or otherwise requires guardian)
______
Date Signed Relationship to Client
YWCA Missoula
1130 W. Broadway
Missoula, MT 59802
T: 406-543-6691
F: 406-543-6777
Ada’s Place Rapid Re-Housing Program
To the applicant: Please detach this sheet from your application and keep for yourself.
The YWCA Ada’s Place Rapid Re-Housing Program housing program designed to assist homeless families in establishing or regaining overall self-sufficiency and housing stability through housing search, rental assistance, and intensive case management. For this program, a family is defined as a group of individuals with one or more parent or primary caregiver who has one or more children under the age of eighteen in their custody.
The following items must be turned in with your application before you are added to the waiting list:
□ Missoula Housing Authority verification
To sign up for public housing and section 8 managed by the Missoula Housing Authority, you must attend an orientation. Orientations are Tuesdays at 5:15pm and Wednesdays at 12:00pm. Orientations are at the Missoula Housing Authority office: 1235 34th Street, Missoula, MT 59801, (406) 549-4113
□ Human Resource Council (Section 8) verification
To sign up for the state section 8 waiting list managed by the Human Resource Council, go to the website listed below and fill out the application. Please print the confirmation page for verification. The Gateway Assessment Center case manager can also fill out this application during one of your case management meetings. The website to fill out the application online is: http://www.housing.mt.gov/about/section8/apply.mcpx
□ Homeless verification letter
This letter must be turned in when during your intake when it is scheduled. The letter must be written from an organization or agency in town that can verify where you slept the night before the intake. You must be considered literally homeless by HUD guidelines meaning that couch surfing or paying for your own hotel room does not qualify. The letter must be written on agency letterhead with the date of the intake.
MTHMIS Client Release of Information for Sharing Client Information with Participating Agencies
This form authorizes the release of client information within the Montana Homeless Management Information System to allow for sharing of information with other participating agencies. The Montana Homeless Management Information System is called the MTHMIS system. Many shelters and other helping programs use the MTHMIS System. The MTHMIS System keeps information about clients that get help here and at other agencies. You must agree to share information before any sharing can occur. Sharing information will help reduce the paperwork you would have to fill out at other agencies. It will also allow agencies to work together to help you.
When I sign below, it means:
· I was told about MTHMIS System and I received a copy of the Privacy and Confidentiality Notice. I know there are both benefits and risks when I agree to share my information. Copy of the Privacy and Confidentiality Notice on last page of application.
· I know that information regarding pregnancy, HIV/AIDS and domestic violence will not be shared with other agencies and that only certain agency workers can view this information.
· I know that there is a list of all the agencies in the MTHMIS System that share information and that I have the right to ask for a list of agencies. These agencies must follow strict privacy laws.
I agree, by initialing the “Yes” below, that information may be shared with other agencies. The agencies that participate in the sharing may change from time to time. Sharing allow other agencies to do a better job helping my family and me.
Client signature Yes: No: Date:
Client signature Yes: No: Date:
Montana Homeless Management Information System (MTHMIS)
Privacy and Confidentiality Notice
MTHMIS – What it does
It is a human services database that keeps track of the clients we serve and the services that we provide. A lot of the questions that agencies typically ask you when you apply for their services are in this database. The database is trying to get an unduplicated “count” of the homeless population in the State of Montana.
Benefits
It reduces some paperwork for ourselves and for you so that we can coordinate services for you and your family more efficiently. It may be used to determine need.
All agencies who participate in the MTHMIS system must be compliant with all state and federal requirements regarding client confidentiality and data security, as well as 42 CFR Part 2 (disclosure of drug and alcohol information) and HIPPA (medical information).
Your rights
You are allowed to view your record, have corrections made to your record, refuse to share your information with other agencies, stop our release of information, and file grievances if necessary.
Security
Everybody that has access to the MTHMIS has been through MTHMIS training as well as Privacy and Confidentiality Training. Only certain people, like your case manager can view confidential parts of your information
Your identifying information will not be used for any reporting from the system. The computer program has the highest degree of security protection available.
Explanation of Release of Information
Maintaining your privacy is very important to us. We believe that the information gathered about you is personal and private. This agency will enter your information into the MTHMIS and has the right to maintain and review this information. If you do not want ANY identifying information entered in MTHMIS, we will input your record without your name and you may still be given service. However, this may make duplicates in the system. We are trying to avoid duplicate entries.
Your information will not be shared with other providers of services without a Release of Information or a signed acknowledgement on the intake form. However, if this agency decides to have partnering relationships with other agencies and wants to share information and you feel uncomfortable with sharing your information within this system, you will not be denied services for which you are otherwise be eligible. If you do not wish to have your information to be seen, we can “hide” it within the MTHMIS from everyone except staff in this agency with a high-level system security role. We want to avoid duplicate records in the system about you. Again, we are trying to avoid duplicate entries.