SandhillsCenter LME 8 CountyCatchment Area

SPMI Group Homes and Apartments

Application

Qualifications of Residents:

  • Adult (at least18 years of age)
  • Severe & Persistent Mental Illness (SPMI) – HUD’s definition of a disability
  • Income eligibility – applicant must be under 30% of area median income

Level of Appropriateness:

  • Mentally stable
  • Medically stable and be able to Self-Medicate (with or without supervision)
  • Basic daily living skills or ability to develop self care skills including basic hygiene skills
  • Willingness to sign lease agreement and follow house rules
  • Be able to live in a co-ed environment, for consumer applying to a group home setting
  • Alcoholism and/or drug addiction issues: Consumer must demonstrate rehabilitation
  • Other relevant information determined by Selection Committee based on applicant’s needs.
  • The following information must be included with the pre-application packet to determine appropriateness: Check off list:

______Release of Information between Service Provider Agency, SandhillsCenter, Therapeutic

Alternatives, and Monarch

______Diagnostic Assessment

______Current Psychiatric Evaluation

______Target Population Eligibility Form

______Person Centered Planning (PCP) for both State and Medicaid Funded

______Current medication list and doctor’s orders

______Court order for Guardianship

______Other relevant information not covered in pre-application packet

Process:

  • Selection Committee Chair will call referral source to schedule interview appointment.
  • Applicant and the referral source meets with Selection Committee and if wanted the applicant’s community support provider, family and/or friend.
  • The meeting is held at the Sandhills Center LME Administration Office-

124 N. Trade St.West End, NC27376 (which is located in 7-Lakes area of MooreCounty off Rt. 211)

  • Send letter to referral source of Selection Committee recommendation to approve or decline level of appropriateness within a week’s time of interview date.
  • If approved for level of appropriateness, the group home or apartment manager will arrange a meeting with the applicant and referral source to complete the HUD Verification packet.

Fax pre-application packet with items from the check off list to 910-673-0904

For assistance with this application or questions callor email

Wanda Feldt, MSW, Housing Specialist

SandhillsCenter MH/DD/SAS ~LME

PO Box 9 – West End, NC27376

Contact info:

Office: (910) 673-0906 ext. 2047

Fax: (910) 673-0904

Email:

Group Home/Apartment Application Fax Cover Sheet

Date:// # of pages being faxed:

To: Wanda Feldt, MSW

Selection Committee Chairperson

SandhillsCenter for MH, DD & SAS

Housing Specialist

Fax: 910-673-0904

From: ______

Agency:______

Phone #: ______Fax #: ______

E-Mail Address:______

Applicant’s county preference: (Please check at least one)

Referral for Group Home preference:

No preference Anson Harnett Hoke Lee

MontgomeryMoore Randolph Richmond

Referral for Apartment preference:

No preference Randolph Richmond

Additional Comments:

______

Monarch and Therapeutic Alternatives, Inc.

Referral Form

Applicant’s Name:______

Last Name First Name Middle Initial ( Maiden Name)

Medical Record #: ______Date of Referral: ______

Birth Date: ______Social Security #: ______

Address: ______

City: ______State: Zip: ____

Telephone: (H) ______(W) ______

Marital Status: S M D W

A)Reason for Referral: ______

B)Number of psychiatric hospitalizations during last two years:

C)Diagnosis: DSM IV Description -do not just write codes, write “none” if nothing applies
AxisIA:

Axis IB:

Axis IIA:

Axis IIB:

Axis III:

D)Current GAF Score:

E)Current Psychiatric Status: ______

F)Transportation: (Please check one)

Owns vehicle Owns scooter Bicycle Walks

Public Transportation None

G)Funding Source: ______

(Medicaid alone is not a funding source please be specific example Medicaid SA)

Medicare #: ______Medicaid #: ______

H)Does Client have a guardian? If so, name address and telephone number of guardian

Name: ______Address: ______

Phone #: ______Relationship: ______

Other Comments: ______

Monarch and Therapeutic Alternatives, Inc.

Referral Form

Applicant’s Name: ______

Part One: Role Problems (check all that apply)

A)SOCIAL ROLE PROBLEMS:

None Lacks activity Social isolation

Isolation worsens symptoms Uncomfortable around others Anxiety in social relationships

Frequently fabricates truth Stealing History of fighting

Destroys property Poor Impulse controls Promiscuity

Exhibitionism Probation Parole

Limited use of community resources Legal problems including convictions/imprisoned

B)EMPLOYMENT ROLE PROBLEMS:

Unemployment No work history

Laid off Frequently fired

Is seeking disability Jobs held briefly (less than one year)

Being employed is high priority for consumer but needs Supported Employment

C)HOUSING ROLE PROBLEMS:

None Homeless Must move

Inappropriate cohabitant Wants but lacks skills to move to less restricted housing

D)EDUCATIONAL ROLE PROBLEMS:

None Behavior problems at school Reading skills issues

Need special education, technical training, other:

Part Two: Other Role Related Problem Areas (check all that apply)

A)RELATIONSHIP PROBLEMS:

None No/Few friends Running away from home

Family desertion Separation or divorce Visitation or custody disputes

Child neglect Child abuse Spouse abuse

Death in family No significant relationships

Conflict with peers, siblings, parents, spouse, significant other, children

Other:

B)FINANCIAL PROBLEMS

None Financial stress Debt-ridden

Reckless spending Bankrupt Destitute

C)SUBSTANCE ABUSE

None D.T.’s Blackouts

Intoxicated now Hospitalizations Family problems

Absenteeism Job Loss Abuse related arrests

History of abuse of:

Narcotic Amphetamines HallucinogensInhalants

Alcohol Cocaine Marijuana

Prescription drugs (which ones)

Current abuse of

NarcoticAmphetaminesHallucinogensInhalants

AlcoholCocaineMarijuana

Prescription drugs (which ones):

Other:

Monarch and Therapeutic Alternatives, Inc.

Referral Form

Applicant’s Name: ______

Part Three: Current Psychiatric Status (check all that apply)

A)Danger to Self:

None Thoughts of suicide Threats of suicide

Hopelessness Preoccupation with death Suicide gestures

Suicide attempts Family history of suicide

Inability to care for self, explain:

B)Danger to Others:

None Thoughts of harm to others Threats of harm to others

Plans to harm others Felt like killing someone Attempts to harm others

Has harmed others Inability to care for dependents, explain

C)Depressive-Like Behavior:

None Sadness Fatigue

Hypoactive Loss of interest Feelings of worthlessness

Guilt feelings Crying Anger

Other:

D)Anxiety-Like Behavior:

None Anxiety Obsessions

Compulsions Phobia Multiple somatic complaints

Other:

E)Manic-Like Behavior:

None Euphoria Sleep disturbance

Hyperactivity Over talkativeness Grandiosity

ExtravaganceOther:

F)Cognitive Problems:

None Recent memory Remote memory

Judgment Comprehensive Attention Span

Decision Making Mental retardation (Borderline, Moderate, Severe)

Orientation (Time, Place, Person, Circumstances)

MR must be tested: Verbal Score Performance Score Full Scale

G)Psychotic/Organic:

None Unmanageable Inability to care for self

Obscene acts Withdrawn Wanders off

Personal hygiene Incoherent Irritability

Hallucinations Delusions Confusion

Acting out/other behavior disorder Orientation (Time, Place, Person, Circumstances)

Other:

H)Explain Need for Higher Level of Care: Check all that apply

Consumer has serious symptoms of impairment in

Social Role Functioning Educational Role Functioning Vocational Role Functioning

and

Less restrictive treatment has:

Failed to improve the role of functioning Is inappropriate

Referring Person’s Name ______Phone #______

Relationship to applicant: ______Date ______

PRELIMINARY APPLICATION FOR ASSISTANCE

Applying to Group Home or Apartment

  1. This section has to be filled out starting with applicant’s information.

Last Name / First Name / DOB / Sex / Relationship to You / Annual Income / Social Security Number
SELF
  1. Do you have a Mental Health diagnosis/and or handicapped? Yes No
  1. Does anyone live with you now who are not listed above? Yes No
  1. Do you expect any change in your household composition?Yes No
  1. If you answered yes to either #3 or #4, please explain:
  1. Are you a student? Yes No
  1. Current Address: Street Address: ______Apt. No

City: ______State: Zip Code: ______

  1. Daytime Phone: ______Evening Phone: ______

Please identify any special housing needs your household has: ______

______

APPLICANT CERTIFICATION: I certify that the statements made on this pre-application are true and complete to the best of my knowledge and belief. I understand that providing false statements or incomplete information may result in punishment under Federal Law.

______

SIGNATURE OF HEAD OF HOUSEHOLD/LEGAL GUARDIANDATE

______

SIGNATURE OF SPOUSE OR CO-HEADDATE

Office Use Only

______Selection Committee Chairperson

RECEIVED BYTITLE

DATE ______TIME______

Revised March 2010 Page 1 of 6