No Limits Incorporated

PROSPERITY HOUSE APPLICATION

PermanentSupportiveHousingApplication

Pleasecompletethe entireapplicationasfullyas possible.Theapplicationwillnotbe consideredcompleteunlessallofthe questionsthathave an asterisk* arecompleted.

Date of Application: ______

APPLICANT(HeadofHousehold)InformationPleasePrintClearly

*FirstNameMI*Last

_

*Street(address at which you receiveyourmail)

*City*StateZip Code

Itis importantthatwecangetin touchwithyou.Pleaseprovideas manyphone numbers as possible.

No Limits Incorporated

PROSPERITY HOUSE APPLICATION

*Primary:()–

*Secondary:()–

No Limits Incorporated

PROSPERITY HOUSE APPLICATION

No Limits Incorporated

PROSPERITY HOUSE APPLICATION

Email:

Additional:()–

No Limits Incorporated

PROSPERITY HOUSE APPLICATION

No Limits Incorporated

PROSPERITY HOUSE APPLICATION

––

//

No Limits Incorporated

PROSPERITY HOUSE APPLICATION

*Social SecurityNumber*BirthDateMedicaid Number

2. Are you chronicallyhomeless?YesNo

3. What is your housing situation? (Housing Status):  Literally Homeless  imminently losing their housing  Unstably Housed and at risk of losing their housing  stably house  Don't know  Refused

4. If Homeless, have you been continuously homeless for a year or more?

 Yes  No  Don’t Know  Refused

5. Number of Times Homeless within the Past Three Years (INCLUDING THIS TIME -choose one):

 0  1  2  3  4  5 to 7  8 to 10  11 or More  Don’t Know  Refused

6. / Race(Voluntary– Pleaseselectone ormore):
White / Blackor AfricanAmerican
AmericanIndian/AlaskanNative / Asian
NativeHawaiian/OtherPacificIslander / AmericanIndian/AlaskanNative andWhite
Asianand White / Black/AfricanAmericanandWhite
AmericanIndian/AlaskanNative and Black / Other
  1. Ethnicity(Voluntary– Pleaseselect“yes”or “no”forHispanicOrigin.)

Hispanic:YesNo

  1. Citizenship(pleasecheck)Areyou a citizen ofthe UnitedStates?YesNo

(Somenoncitizensareeligibleforthisprogram)

  1. Gender(pleasecheck)MaleFemale
  1. Veteran(pleasecheck)YesNo
  1. NearElderly-Defined asa head ofhousehold 55to 61years ofage(pleasecheck)YesNo
  1. Elderly-Definedas a headofhouseholdover62yearsofage(pleasecheck)YesNo
  1. AgingOutYouth:YouareagingoutofthestateFosterCaresystem

(pleasecheck)YesNo

  1. Accessibility:Doesamemberofyourhouseholdrequireanyofthefollowing?(Ifsopleasecheckyesand belowwhichaccommodation(s) you need) Yes No

WheelchairHandicappedAccessibleParkingGrabbarsandHandrailsNo StepsFew Steps HearingDisability Modificationforvisionor hearingimpairmentRollin shower

Pleaseexplain

HouseholdInformation

Listallotherpersonswhowillbelivingin theunitandtheirrelationship tothe HeadofHousehold.Complete theinformationinthe chartforallmembers ofthe household.(Thiscanincludeunrelatedpeople.)Whenunrelatedpersonswithdisabilitiesarelivingtogethersharingsupports,onepersonshouldbedesignatedasapplicantandheadof household.Otherpersonsshould belistedin thechart,withrelationshipas"roommate."

FirstName / LastName / Relationto Head / Birth Date / Age / Sex / SocialSecurity#
Head

Do you require24-hourcare by acaretakeror live-inaide?YesNo

Disability

In orderto helpyouaccessany neededsupportsitishelpfulfor us toknow whattype ofdisabilityyouhave. Pleasecheckallthatapply.

DevelopmentalDisability-defined asa disabilitythat occurredbeforetheage of22.

  1. Acquiredagebirth– 3 yrs
  2. Acquiredage 3–21 yrsSeriousMentalIllness;
  3. MentalIllness
  4. MentalIllnesswithSubstanceAbuse

DisabilityAcquiredaftertheageof22(e.g.,physicaldisability,sensorydisability,disabilitycausedby

chronicillness,disabilitycaused byHIV/AIDS);orAge-relateddisability(i.e.,“frailelderly”).

Other

Do you haveVeryLowincome?(Defined as 50%ofAreaMedianIncome)Pleaserefertochartbelow

YesNo

Source of Income: ______

Employer if applicable: ______

Provide proof of income by way of Paystubs or SSI/ATAP benefits printout.

AUTHORIZATION FOR RELEASEOF INFORMATION

Name:Dateof Birth: ______

SocialSecurity#: P.O. Name (ifapplicable):

OCS Involvement(ifapplicable): ______

PURPOSE:Theinformationreleased willbeusedtoevaluatemysituationandtoplanforandcoordinateservices forme,or for otherpurposesasspecified.

Iauthorize:(Name &Address) and (Name &Address)

Phone:Fax:Phone:Fax:

Toprovideinformationtothefollowingindividuals/agencies:

InitialReleaseTo:Purpose:

(Name &Address)
Phone: / Fax:
(Name &Address)
Phone: / Fax:

Checktheboxandinitialaftereachtypeofrecordforwhichyouareauthorizingrelease:

Initial Initial

FamilyHistoryRecordEducationalEmployment/WorkRecords Alcohol/DrugTreatment/MedicalRecords MentalHealthServices* Information/recordsasspecified:

Educationalreports includebothbehavioralandprogress reports.Alcohol/drugTreatment,Mental

HealthServicesandmedical/psychiatricrecords includeallaspects of diagnosis,treatmentandprognosis.

This permissionisgoodfor six(6)monthsfromthedateof yoursignature.

Icancancelthisatanytime.Iunderstandthecancellationwillnotaffectanyinformationthatwasreleasedbefore thecancellation.Iapprovethereleaseofthisinformation.Iunderstandthatinformationaboutmycaseis confidential andprotectedbystateandfederallaw.Iunderstandwhatthisagreementmeans.Iamsigningonmy own andhavenotbeenpressuredtodoso.

SignatureDate

Witness SignatureDate

______

Thisportionoftheform(pages 78) needsto becompleted byyou and a serviceprofessional,thatcanattesttoyourneedforsupportiveservices.Examplesofaprofessionalcanincludeasocialworker,asupportcoordinator, anurse, ora doctor.

PrintedNameofProfessionalcompleting ContactInformation(email/ phone) AgencyAddress

NeedforHousingsupports

HousingHistory:

HastheApplicant:

1.Livedfor a periodofmorethan 90days inan institution(publicorprivateIntermediateCareFacility/Developmental Disability,nursinghome,psychiatrichospital,other facility)?

YesNoApproximatetermof institutionalization:

2.Lived atsomepointindependentlyinhis/herownapartmentorhome? YesNo

3.Everbeenevicted? Yes No

Reason(s)foreviction(number ofevictions andreason):

Housingneeds:

Ratethefollowingsupportareaspertheneedsof the Applicant

NeverSometimesOften1. Needssupporttoidentifypreferencesrelatedtohousing (location,

accommodationsneeded, feasibilityofaccessing otherneeded supports oractivities)

NeverSometimes / Often / 2. Needssupporttomaintainhousing,including assistance toaccess
appropriate housing options,obtainingnecessarydocuments andrecords to
complete housing application or lease,obtain/access sources ofincome
necessarytopayrent,home management,establishcredit,and understandandmeet obligationsoftenancyas definedinlease terms
Never / Sometimes / Often / 3. Needsassistance tocommunicatewiththelandlordorpropertymanagerregarding the Applicant’sdisability, accommodations needed(wheelchairramp, bathgrab bars, etc.),neededrepairs,or otherunitconcerns
Never / Sometimes / Often / 4.Needsassistancetocommunicatewith neighbors(Forexample,resolvingdisputes ina calmmanner)
Never / Sometimes / Often / 5.Needsassistancewithhouseholdbudgetingtoensurepaymentofrentandavoidutilitydisconnection
Never / Sometimes / Often / 6. Needsassistance keeping appointments andproviding paperworknecessarytomaintainaccess toincome/benefits.

Doestheapplicantor memberofthehouseholdhaveasubstantial,long-termdisabilityincludingbutnotlimitedtoseriousmentalillness,Co-occurringdisorder(mentalillnessandsubstanceusedisorder),developmentaldisability,physicalorsensorydisability,disabilityduetoaging(i.e.“frailelder”)ordisabilitydue to HIV/AIDS?

Yes No

DoestheapplicantormemberofthehouseholdneedtheSupportiveServicesprovided bythe PSHprogram toallow you to live inthecommunityand notbecomeevictedorhomeless?

Yes No

Attestation:

I attestthat I haveassessed thisindividualand/ortheirhouseholdmemberand I believethepersonand/orhouseholdmeetsthecriteriaofbeingin needofpermanentsupportivehousingservices.

SignatureofProfessionalCompletingDate