Shelter Plus Care Referral

Shelter Plus Care (Home Again) and Supportive Housing (DASH) Application

PLEASE NOTE: * All applicants must be disabled and currently homeless to qualify. * Shelter Plus Care (S+C) referring agencies must supply evidence of matching funds quarterly. * Supportive Housing (DASH) recipients must meet the HUD criteria for homelessness or chronic homelessness.

Date of Referral: Completed by:

Referring Agency:

Agency Phone: Agency Fax:

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  Shelter Plus Care Program Screening Screening The household has VI-SPDAT score of 10 or higher The household has VI-SPDAT score of 10 or higher AND AND meets one the following: meets one the following: Homeless continuously for at least one year Homeless continuously for at least one year (i.e., streets, shelter, condemned building) (i.e., streets, shelter, condemned building) Has had at least 4 episodes of homelessness in the Has had at least 4 episodes of homelessness in the past 3 years (i.e., streets, condemned building, etc.) past 3 years (i.e., streets, condemned building, etc.) Living in a publicly or privately operated Living in a publicly or privately operated emergency shelter emergency shelter Living in places not meant for human habitation Living in places not meant for human habitation (i.e., streets, condemned building, etc.) (i.e., streets, condemned building, etc.) Living in transitional housing, but came there Living in transitional housing, but came there from places not meant for human habitation OR from places not meant for human habitation OR emergency shelter emergency shelter Exiting an institution (hospital, jail, etc) where Exiting an institution (hospital, jail, etc) where resided for 90 days or less and lived in an resided for 90 days or less and lived in an emergency shelter or places not meant for emergency shelter or places not meant for human human habitation immediately before entering habitation immediately before entering institution institution None of the above (household is ineligible for None of the above (household is ineligible for S+C) SHP)

DASH/Home Again Application Packet p. 1 of 15 Jan 2015 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 violent criminal activity within the last 3 years? 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  Yes  No “Quarterly Reporting Form” and return them quarterly to Housing Coordinator. (*NOTE: If no, then do NOT refer this person )

Referral Information

Name of Agency QP

QP Number QP Email

DASH/Home Again Application Packet p. 2 of 15 Jan 2015 Name of Applicant SS# Current address or place of residence: What type of residence is this (e.g., emergency shelter, transitional facility, motel, overcrowded situation household, family/friends, etc.)? City/County last permanent address: Last permanent address zipcode: How can the applicant be contacted? 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 7 a. 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

DASH/Home Again Application Packet p. 3 of 15 Jan 2015 List the names of the people who will be living with the applicant Name Relationship Age Has birth 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 Information APR 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

DASH/Home Again Application Packet p. 4 of 15 Jan 2015 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 [email protected]

DASH/Home Again Application Packet p. 5 of 15 Jan 2015 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 Authority Durham County Department of Social Services Private Provider (MH/SA/IDD) Administrative Office of the Court Other: Other: Other: Other:

Signatures

______Signature of Applicant Date

______Signature of Witness Date

Email copy of the completed Authorization for Release of Information to:

Housing Coordinator Community Relations Department Valaria Brown [email protected]

DASH/Home Again Application Packet p. 6 of 15 Jan 2015 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 Authority Durham 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 Applicant Date

______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 [email protected]

DASH/Home Again Application Packet p. 7 of 15 Jan 2015 Applicant Name: DOB:

Directions: Place an X in the appropriate box for each disability section or choose “Not applicable.”

Section 1. Visual Disabilities Not applicable

Has 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 applicable

Has 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 applicable

Has 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 applicable

Is 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 medical doctor, psychiatrist, psychologist, LPC, LCSW, or Nurse Practitioner trained to make determinations. A case manager or qualified professional does NOT qualify.

Agency Name Telephone

Address City Zip Code

______Print Name & Title Signature Date

DASH/Home Again Application Packet p. 8 of 15 Jan 2015 Service Provider Agreement

PLEASE NOTE: The issuing agency may terminate the Supportive Housing subsidy of any recipient who fails to meet comply with requirements of the program.

PLEASE NOTE: For your client to receive Supportive Housing, the recipient is strongly encouraged to engage in support services during the recipient’s time in the Supportive Housing program to 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 Healthcare the 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: 1. Changes to the client’s service providers that might impact matching fund documentation 2. Changes to the services provided to the client that might impact matching fund documentation 3. Changes to the treatment plan that might impact matching fund documentation 4. Changes to the client’s assigned caseworker and contact information 5. Changes to the client’s income or employment that might impact the client’s rent subsidy 6. 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 Agent Name of Referring Agency Date

______Signature of Alliance Behavioral Healthcare Housing Coordinator Date

DASH/Home Again Application Packet p. 9 of 15 Jan 2015 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 who does not comply with lease, 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 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 Tenant Date

______Signature of Alliance Behavioral Healthcare Housing Coordinator Date

DASH/Home Again Application Packet p. 10 of 15 Jan 2015 DASH/Home Again Application Packet p. 11 of 15 Jan 2015 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 required documentation 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!)

DASH/Home Again Application Packet p. 12 of 15 Jan 2015 Documentation of Homelessness Guide

Each Shelter Plus or Permanent Supportive Housing Screening and Referral Form must contain the required evidence of homelessness. Please use the list below to make sure that the correct supporting documentation is submitted.

1. Places Not Meant for Human Habitation: Certification form signed by the outreach worker or service worker verifying that the person or family is homeless. This could include a letter or certification form signed by an outreach worker or service worker from another organization that can verify that the person or family was, in fact, homeless as described in the above definition, OR

2. Places Not Meant for Human Habitation: Written statement prepared by the participant about the participant’s previous living place (if unable to verify by outreach worker or service worker). Have the participant sign and date.

3. Shelter: Referral agency certification that the participant has been residing on the street or at the emergency shelter (on agency letterhead, signed and dated).

4. Transitional housing (for S+C applicants only): Certification (on agency letterhead, signed and dated) if the participant is residing at the transitional housing facility AND written verification that the participant was living on the streets or an emergency shelter prior to living in the transitional housing facility (see above for required documentation).

Please note that this application will NOT be processed unless the applicant and/or referring agency can provide this documentation.

STOP STOP STOP STOP STOP STOP STOP DASH/Home Again Application Packet p. 13 of 15 Jan 2015 Official Use Only – Housing Selection Committee Approval Sheet

This person meets the criteria for homeless?  Yes  No This person meets the criteria for chronic homeless?  Yes  No This person has a qualifying disability?  Yes  No

There is evidence of (check all that apply):

 Mental Illness  Developmental Disability  Alcohol Abuse  Physical Disability  Drug Abuse  Visual Disability  HIV/AIDs and related diseases  Domestic Violence

The referral agency completed the “Provider Agreement?”  Yes  No

Official Use Only – Housing Selection Committee Comments

Official Use Only – Housing Selection Committee Decision

Based on the information included in this Referral Form, the applicant’s request has been:  Denied due to:  Lack of documentation: ( Criminal  Disability  Homelessness  Finances  Birth Certificate  S.S. Card)  Applicant does not meet the criteria for homelessness or chronic homelessness  Applicant does not have a documented disability  Applicant has an arrest for a drug or violent related offense in the last three years  Other:  Denied because the applicant no longer meets the criteria for homelessness.  Approved and placed on the S+C waiting list.  Approved and placed on the DASH waiting list.  Approved and placed on the Embrace Durham waiting list.

Referral Authorized By: Date:

DASH/Home Again Application Packet p. 14 of 15 Jan 2015 Housing Exit Information

Directions: Complete this form when the tenant leaves the program.

Name DOB

Exit Date XXXXXXXXXX X Which program is the person leaving? S+C XX SHP XX

Monthly Income at Exit Income Sources At Exit Support Services Received (APR 11-B) (APR 11-D) (Choose All That Apply) (APR 15) (Choose all that apply) a. No income a. Supplemental Security Income (SSI) a. Outreach b. $1-150 b. Social Security Disability Income (SSDI) b. Case management c. $151 - $250 c. Social Security c. Life skills (besides case management) d. $251- $500 d. General Public Assistance d. Alcohol and drug abuse services e. $501 - $1,000 e. Temporary Aid to Needy Families (TANF) e. Mental health services f. $1001- $1500 f. State Children’s Health Insurance Program (SCHIP) f. AIDS-related services g. $1501- $2000 g. Veterans Benefits g. Other health care services h. $2001 + h. Employment Income h. Education i. Unemployment Benefits i. Housing placement j. Veterans Health Care j. Employment assistance k. Medicaid k. Child care l. Food Stamps l. Transportation m Other (please specify) m Legal . . n. No Financial Resources n. Other (please specify)

Length of Stay Primary Reason for Leaving Program Destination after exit from program (APR 12) (APR 13) (Choose only one) (APR 14) (Choose only one) Left for a housing opportunity before completing a. Less than 1 month a. a. Rental house or apartment (no subsidy) program b. 1 to 2 months b. Completed program b. Public Housing c. 3 - 6 months c. Non-payment of rent/occupancy charge c. Section 8 d. 7 - 12 months d. Non-compliance with project d. Shelter Plus Care e. 13 - 24 months e. Criminal activity / destruction of property / violence e. HOME subsidized house or apartment f. 25 - 3 years f. Reached maximum time allowed in project f. Other subsidized house or apartment g. 4 - 5 years g. Needs could not be met by project g. Homeownership h. 6 - 7 years h. Disagreement with rules/persons h. Moved in w/ family/friends (permanent) Transitional housing for homeless i. 8 - 10 years i. Death i. persons j. Over 10 years j. Other (please specify) j. Moved in w/ family/friends (transitional) k. Unknown/disappeared k. Psychiatric hospital l. Inpatient AOD treatment facility m Jail/prison . n. Emergency shelter o. Other supportive housing p. Places not meant for human habitation q. Other (please specify) Signature Date r. Unknown

DASH/Home Again Application Packet p. 15 of 15 Jan 2015