Ada’s Place Emergency Housing
Family Application
The YWCA Ada’s Emergency Housing is a housing program designed to assist homeless families in establishing or regaining overall self-sufficiency and housing stability through 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.
It is the YWCA 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.
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, 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 □School-aged children must be registered and attending school.
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 weekly basis.
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.
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 SignatureDate
______
Adult Two SignatureDate
______
Gateway Assessment Center Staff SignatureDate
Today’s Date: Section 8 Waiting List?
️ Applied MHA
Phone number: ______Additional Contact: ______️ Applied HRC
Demographic Information
Family or Household Member and Relationship to Applicant / First & Last Name / Privacy Code8 digits
(for office use only) / Birth Date
(00/00/00) / Relationship to
Head of Household
(CODE) / In School/
Name of School
(CODE) / Pregnant
(CODE) / Ethnicity
(CODE) / Race
(CODE) / Gender
(CODE) / Veteran Status
(CODE) / Disabling Condition (CODE)
Head of
Household / /
Adult 2 / /
Child 1 / /
Child 2 / /
Child 3 / /
Child 4 / /
Child 5 / /
Housing Information
Zip Code of Last Permanent AddressLength of Stay in Previous PlaceCurrent Housing Status
️One day or less️Homeless
️Two days to one week️ At imminent risk of losing housing
️ More than one week, but < than one month️ Homeless only under other federal statues
️One to three months️ Fleeing domestic violence
️More than three months, but < than one year️ At-risk of homelessness ️One year or longer ️Stably housed ️Don’t know ️Don’t know
️Refused️Refused
CurrentResidence
️Emergency shelter including hotel/motel paid with shelter voucher️Foster 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 home️Safe Haven
️Substance abuse treatment facility or detox center️Rental by client, with VASH housing subsidy
️Residential project or halfway house with no homeless criteria️Rental 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 facilityhousing subsidy
️Staying or living in a family member’s room, apartment or house️Owned by client, with ongoing housing subsidy
️Staying or living in a friend’s room, apartment or house️Rental by client, no ongoing housing subsidy
️Hotel or motel paid for without emergency shelter voucher️Owned 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 less️One week or less
️More than one week, less than one month️More than one week, less than one month
️One to three months️One to three months
️More than three months, less than one year️More than three months, less than one year
️One year or longer️One 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 yearNumber of times homeless in the past 3 yearsIf 4 or more, total number of months homeless in the past 3 years
️No️0️0-12 months
️Yes️1️More than 12 months
️Don’t know️2️Don’t know
️Refused️3️Refused
️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?
️No️No
️ 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?
️No️ No
️Yes️Yes
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 ️ Missoulain the past year?
️ Once️Elsewhere in Montana️No
️2-3 times️Another state️Yes ➔ ➔ If Yes, how many weeks?
️4 or more times️Don’t know️Don’t know
️ Don’t know️ Refused️ 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 formaleviction?
️No️ No ️No
️Yes️Yes➔ ➔ If Yes, when last time made a mortgage payment?______️ Yes
️ Don’t know️Don’t know (month/ year)️Don’t know
️Refused️Refused ️Refused
Do you have a place to live in right now? If Yes, is this place: (check any that apply)
️ No️ No️Yes - Adequate (i.e., good repair; repairs done if requested)
️ Yes ️ No️Yes - Affordable (costs no more than 30% of your total income)
️Don’t know️No️Yes - Stable (you are not at risk of eviction)
️ Refused️ No️Yes - In a safe neighborhood
What is preventing you from being housed right now or is causing you difficulties in maintaining your housing?(check all that apply) / Response / What is preventing you from being housed right now or is causing you difficulties in maintaining your housing?
(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?️ No️ Don’t know️ Yes️Refused
Household Income Source / Receiving Income Source? / Amount from Source Monthly / HouseholdIncome Source / Receiving Income Source? / Amount from Source MonthlyEarned income (i.e., employment income) / ️No
️Yes / $______.00 / Retirement income from Social Security / ️No
️Yes / $______.00
Unemployment Ins. / ️No
️Yes / $______.00 / Veteran’s pension / ️No
️Yes / $______.00
Supplemental Security Income (SSI) / ️No
️Yes / $______.00 / Pension from a former job / ️No
️Yes / $______.00
Social Security Disability Income (SSDI) / ️No
️Yes / $______.00 / Child support / ️No
️Yes / $______.00
Veteran’s disability insurance / ️No
️Yes / $______.00 / Alimony or other spousal support / ️No
️Yes / $______.00
Private disability insurance / ️No
️Yes / $______.00 / Other source / ️No
️Yes / $______.00
Worker’s comp / ️No
️Yes / $______.00
Temporary Assistance for Needy Families (TANF) / ️No
️Yes / $______.00 / Total Monthly Income / $______.00
If household earned income from above, what are hourly wages?/ hourWhat kind of work?
Have you received non-cash benefits from any sources in the past 30 days?️ No️ Don’t know️ Yes️Refused
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 Source? / Monthly Amount from Source / Non-Cash Benefit Source / Receiving Benefit Source? / Amount from Source MonthlySNAP (food stamps) / ️No
️Yes / $______.00 / TANF Child Care Services / ️No
️Yes
Temporary Rental Assistance / ️No
️Yes / $______.00 / TANF Transportation Services / ️No
️Yes
Section 8, Public Housing Voucher, or Shelter Plus Care Voucher / ️No
️Yes / $______.00 / Other TANF-funded Services / ️No
️Yes
MEDICAID / ️No
️Yes / WIC / ️No
️Yes
MEDICARE / ️No
️Yes / Veteran’s Administration (VA) Medical Services / ️No
️Yes
Healthy Montana Kids (SCHIP) / ️No
️Yes / Other non-cash benefit source
(Please specify:______) / ️No
️Yes / $______.00
Social Supports
In the past 12 months, have there been any important changes or losses in your family/support system?
️ No️ YesMy family/friends are very supportive.
️ No️ YesI live far away from family/friends.
️ No️ YesI have lost support through interpersonal conflict.
️ No️ YesI have lost support through the death of a caregiver, family member or friend.
️ No️ YesI 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?
️ None️ Some college
️ 8th grade or less️Bachelors degree
️ 9th, 10th, 11th, or 12th (no diploma)️Graduate degree
️High school diploma or GED️Don’t know
️Technical school credential️ 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 PAST90 DAYS
Shelter / Used / Housing Assistance / Used / Food/Meals / Used / Health Care / UsedPoverello / ️ No
️Yes / Salvation Army / ️ No
️Yes / Food stamps (SNAP) / ️ No
️Yes / Partnership Health Center (physical, mental, dental) / ️ No
️Yes
YWCA Pathways Domestic Violence Shelter / ️ No
️Yes / Veterans Admin (VA) / ️ No
️Yes / WIC / ️ No
️Yes / Local hospital / ️ No
️Yes
WMMHC Share House / ️ No
️Yes / Human Resource Council / ️ No
️Yes / Free and Reduced School Lunch / ️ No
️Yes / Other dental care / ️ No
️Yes
WMMHC Stephens House / ️ No
️Yes / YWCA / ️ No
️Yes / Missoula Food Bank / ️ No
️Yes / Vision care / ️ No
️Yes
WMMHC Dakota House / ️ No
️Yes / HomeWord / ️ No
️Yes / Poverello / ️ No
️Yes / Prescription medication cost assistance / ️ No
️Yes
YWCA Gateway Center / ️ No
️Yes / WORD / ️ No
️Yes / Union Gospel Mission / ️ No
️Yes / Private physician / ️ No
️Yes
Motel voucher - Union Gospel Mission / ️ No
️Yes / Western Montana Mental Health / ️ No
️Yes / Salvation Army / ️ No
️Yes / Veterans Administration / ️ No
️Yes
Motel voucher - YWCA Gateway / ️ No
️Yes / Missoula Housing Authority / ️ No
️Yes / Churches / ️ No
️Yes / Mental Health Services / ️ No
️Yes
Church provided shelter / ️ No
️Yes / Poverello / ️ No
️Yes / Other / ️ No
️Yes / Western MT Mental Health / ️ No
️Yes
Family Promise / ️ No
️Yes / Union Gospel Mission / ️ No
️Yes / Poverello / ️ No
️Yes
Mountain Home Montana / ️ No
️Yes / Other / ️ No
️Yes / Missoula Urban Indian Health Center / ️ No
️Yes
Turning Point (substance abuse treatment) / ️ No
️Yes
Disability services / ️ No
️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 nameDischarge 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 SignatureDate
Adult Two SignatureDate
Gateway Assessment Center Staff SignatureDate
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
Emergency Contact Information:
Name: ______
Phone Number: ______
City and State of Residence: ______
Relationship to Applicant: ______
Vehicle Information:
Year, Make, and Model: ______
Color: ______
License plate number: ______
Pet Policy:
Pets are not allowed on the premises (including service/companion animals).
Do you have a pet? _____ Yes _____ No
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 SignedRelationship to Client
To the applicant: Please detach this sheet from your application
and keep for yourself.
Ada’s Place Emergency Housing
The YWCA Ada’s Place Emergency Housing is a 50 day housing program designed to assist homeless families in establishing or regaining overall self-sufficiency and housing stability through 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 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: . You can also apply in person at 1801 S Higgins Ave.
□ Homeless verification letter
This letter must come from another organization or agency stating that you’re homeless and where you are staying. 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 a date and signature.
While working with the Gateway Assessment Center, participants are required to meet with the case manager at least every other week. If it has been more than two weeks since your last case management meeting, your file will be closed and you will be taken off of the waiting list.
Prior to entering the hotel room, a $50 security deposit is required to protect against damages and additional cleaning fees. The security deposit is due at the signing of the Program Agreement and will only be accepted in the form of check or money order.
Gateway Assessment Center
355 S Russell (in Salvation Army)
Missoula MT 59801
406-549-0710
Office Hours:
Monday, Thursday, Friday 12 – 4PM
Wednesday 9AM – 1PM