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:  Families who are currently housed.  Families who do not have children living with them at least 50% of the time.  Families who are staying with relatives or friends long-term.  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

Updated 10/2016 Today’s Date: Section 8 Waiting List? Applied MHA Phone number: ______Additional Contact or email address: ______Applied HRC

Demographic Information

Family or Privacy Relationship Vetera Household Code Birth to In School/ Pregna Ethnici Gende n Disabling Member and 8 digits Date Head of Name of nt ty Race r Status Conditio Relationship First & Last Name (for office (00/00/0 Household School (CODE (CODE (CO (COD (CODE n to Applicant use only) 0) (CODE) (CODE) ) ) DE) E) ) (CODE) Head of / Household Adult 2 / Child 1 / Child 2 / Child 3 / Child 4 / Child 5 /

CODES

Privacy Code Relationship to Head of Household In School Pregnant Ethnicity 1st letter of 1st name 1 = self (head of household) 0 = No 0 = No 0 = Non-Hispanic/Non-Latino 1st letter of last name 2 = head of household child 1 = Yes 1 = Yes 1 = Hispanic/Latino 2nd letter of last name 3 = head of household spouse or partner 8 = Don’t know 8 = Don’t know 8 = Don’t know Gender (M, F, or T) 4 = head of household other relative member 9 = Refused 9 = Refused 9 = Refused Birth month and year (4 digits) (other related to head of household) (Privacy code is 8 digits total) 5=other non-relative member ALL CAPS

Race Are you of more than one race? Gender Vet Status Disabling Condition 1 = American Indian or Alaskan Native Yes 0 = Female 0 = No 0 = No 2 = Asian No 1 = Male 1 = Yes 1 = Yes 3 = Black or African American 2 = Transgender M to F 8 = Don’t know 8 = Don’t know 4 = Native Hawaiian or Other Pacific Islander 3 = Transgender F to M 9 = Refused 9 = Refused 5 = White 4 = Other 8 = Don’t know 8 = Don’t know 9 = Refused 9 = Refused Housing Information

Zip Code of Last Permanent Address Length of Stay in Previous Place Current Housing Status One day or less Homeless Two days to one week At imminent risk of losing housing More than one week, but < than one month Homeless only under other federal statues One to three months Fleeing domestic violence More than three months, but < than one year At-risk of homelessness One year or longer Stably housed Don’t know Don’t know Refused Refused Current Residence Emergency shelter including hotel/motel paid with shelter voucher Foster care home or foster care group home Transitional housing for homeless persons (including homeless youth) Place not meant for habitation* Permanent housing for formerly homeless persons (HUD Legacy Program or HOPWA PH) Psychiatric hospital or other psychiatric facility Long-term care facility or nursing home Safe Haven Substance abuse treatment facility or detox center Rental by client, with VASH housing subsidy Residential project or halfway house with no homeless criteria Rental by client, with GPD TIP subsidy Hospital or other residential non-psychiatric residential facility) Rental by client, with other (non-VASH) ongoing Jail, prison or juvenile detention facility housing subsidy Staying or living in a family member’s room, apartment or house Owned by client, with ongoing housing subsidy Staying or living in a friend’s room, apartment or house Rental by client, no ongoing housing subsidy Hotel or motel paid for without emergency shelter voucher Owned by client, no ongoing housing subsidy Don’t know Refused Other If checked, please specify:

(* Place not meant for habitation means the following: a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside)

How Long Have You Been Living/Sleeping There? How Long Have You Lived in the Missoula Community One week or less One week or less More than one week, less than one month More than one week, less than one month One to three months One to three months More than three months, less than one year More than three months, less than one year One year or longer One year or longer

Length of Time on the Street, in Emergency Shelter or Safe Haven (ONLY ANSWER THE NEXT FOUR ITEMS IF CURRENTLY HOMELESS)

Continuously homeless for at least 1 year Number of times homeless in the past 3 years If 4 or more, total number of months homeless in the past 3 years No 0 0-12 months Yes 1 More than 12 months Don’t know 2 Don’t know Refused 3 Refused 4 or more Don’t know Refused Total number of months continuously homeless immediately prior to data entry ______(months)

Status documented No Yes

Housing Transitions

In the past 5 years, have you spent time in a mental health or addictions care facility? In the past 5 years, have you spent time in a correctional facility? No No Yes ➔ ➔ If Yes, approximately how many weeks? Yes ➔ ➔ If Yes, approximately how many weeks?______⬇ ⬇ If Yes, did you have stable housing to move into upon your return to the community? If Yes, did you have stable housing to move into upon your return to the community? No No Yes Yes

Housing Stability

How many times have you moved in the past 12 months? Where was your last permanent housing? Have you ever had to stay with friends/family None Missoula in the past year? Once Elsewhere in Montana No 2-3 times Another state Yes ➔ ➔ If Yes, how many weeks? 4 or more times Don’t know Don’t know Don’t know Refused Refused Refused

When was the last time you paid rent with your own money for an apartment or house you rented? (Month and Year)

Have you ever had your name on a lease? Have you ever owned a home? Have you ever received a formal eviction? No No No Yes Yes ➔ ➔ If Yes, when last time made a mortgage payment?______Yes Don’t know Don’t know (month/ year) Don’t know Refused Refused Refused

Do you have a place to live in right now? If Yes, is this place: (check any that apply) No No Yes - Adequate (i.e., good repair; repairs done if requested) Yes No Yes - Affordable (costs no more than 30% of your total income) Don’t know No Yes - Stable (you are not at risk of eviction) Refused No Yes - In a safe neighborhood What is preventing you from being housed right now What is preventing you from being housed right or is causing you difficulties in maintaining your now or is causing you difficulties in maintaining housing? your housing? (check all that apply) Response (check all that apply) Response Domestic violence in the home No Yes One or more misdemeanors No Yes Alcohol or other drug abuse No Yes Critical felony (sex crime, arson, drugs) No Yes Mental illness No Yes Lack of affordable housing No Yes Disability No Yes Lack of steady full time employment No Yes Physical illness/injury (temporary) No Yes Lack of reliable transportation to maintain a job No Yes Poor reference from current/prior landlords No Yes Lack of reliable/affordable childcare No Yes Lack of rental history No Yes Limited English proficiency No Yes Unpaid rent or utility bills No Yes Lack of high school diploma or GED No Yes Lack of or poor credit history No Yes

Financial Resources, Social Supports, and Youth Factors Financial Resources

Has your household received income from any sources in the past 30 days? No Don’t know Yes Refused

Household Income Source Receiving Income Amount from Household Income Source Receiving Income Amount from Source Source? Source Monthly Source? Monthly Earned income (i.e., employment No Retirement income from Social No $______.00 $______.00 income) Yes Security Yes No No Unemployment Ins. $______.00 Veteran’s pension $______.00 Yes Yes No No Supplemental Security Income (SSI) $______.00 Pension from a former job $______.00 Yes Yes Social Security Disability Income No No $______.00 Child support $______.00 (SSDI) Yes Yes No No Veteran’s disability insurance $______.00 Alimony or other spousal support $______.00 Yes Yes No No Private disability insurance $______.00 Other source $______.00 Yes Yes No Worker’s comp $______.00 Yes Temporary Assistance for Needy No $______.00 Families (TANF) Yes Total Monthly Income $______.00

If household earned income from above, what are hourly wages? / hour What kind of work? Have you received non-cash benefits from any sources in the past 30 days? No Don’t know Yes Refused If checked Yes, complete Non-Cash Benefit Source below. If any other item is checked, skip Non-Cash Benefit Source below.

Non-Cash Benefit Source Receiving Benefit Monthly Amount Non-Cash Benefit Source Receiving Benefit Amount from Source Source? from Source Source? Monthly No No SNAP (food stamps) $______.00 TANF Child Care Services Yes Yes No No Temporary Rental Assistance $______.00 TANF Transportation Services Yes Yes Section 8, Public Housing Voucher, or No No $______.00 Other TANF-funded Services Shelter Plus Care Voucher Yes Yes No No MEDICAID WIC Yes Yes No Veteran’s Administration (VA) No MEDICARE Yes Medical Services Yes No Other non-cash benefit source No Healthy Montana Kids (SCHIP) $______.00 Yes (Please specify:______) Yes

Social Supports In the past 12 months, have there been any important changes or losses in your family/support system? No Yes My family/friends are very supportive. No Yes I live far away from family/friends. No Yes I have lost support through interpersonal conflict. No Yes I have lost support through the death of a caregiver, family member or friend. No Yes I have family/friends that could help me with housing and/or finances for a while if I needed.

Have you experience domestic violence or sexual assault in the last 2 years? ️️No ️️Yes

Are you required to register as a violent or sexual offender? ️️No ️️Yes

Education and Childhood/Youth Factors What is the highest level of education you have completed? None Some college 8th grade or less Bachelors degree 9th, 10th, 11th, or 12th (no diploma) Graduate degree High school diploma or GED Don’t know Technical school credential Refused

As a child or youth were you ever in the foster care system or other youth facility? No Yes

If Yes, how many different placements? If Yes, in total how MONTHS in foster care system or other youth facility? (months)

Service Usage and Frequency Services Used in the PAST 90 DAYS

Use Shelter Used Housing Assistance Used Food/Meals Used Health Care d No No No Partnership Health Center No Poverello Salvation Army Food stamps (SNAP) Yes Yes Yes (physical, mental, dental) Yes YWCA Pathways Domestic No No No No Veterans Admin (VA) WIC Local hospital Violence Shelter Yes Yes Yes Yes

No No Free and Reduced School No No WMMHC Share House Human Resource Council Other dental care Yes Yes Lunch Yes Yes No No No No WMMHC Stephens House YWCA Missoula Food Bank Vision care Yes Yes Yes Yes No No No Prescription medication cost No WMMHC Dakota House HomeWord Poverello Yes Yes Yes assistance Yes No No No No YWCA Gateway Center WORD Union Gospel Mission Private physician Yes Yes Yes Yes Motel voucher - Union No Western Montana Mental No No No Salvation Army Veterans Administration Gospel Mission Yes Health Yes Yes Yes Motel voucher - YWCA No No No No Missoula Housing Authority Churches Mental Health Services Gateway Yes Yes Yes Yes No No No No Church provided shelter Poverello Other Western MT Mental Health Yes Yes Yes Yes No No No Family Promise Union Gospel Mission Poverello Yes Yes Yes No No Missoula Urban Indian No Mountain Home Montana Other Yes Yes Health Center Yes Turning Point (substance No abuse treatment) Yes No Disability services Yes

Are there services you need you have not been able to get? No Yes ➔ ➔ If Yes, what services? 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

Gateway Assessment Center Staff Signature Date

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

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 domes tic 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

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.

PRIVACY NOTICE AMENDMENTS: The policies covered under this Privacy Notice may be amended over time and those amendments may affect information obtained by the agency before the date of the change. 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.