Common Permanent Supportive Housing Application

CHARLOTTE/MECKLENBURG COMMON APPLICATION

FOR PERMANENT SUPPORTIVE HOUSING

The following is a common application that has been developed by Charlotte/Mecklenburg County permanent supportive housing providers. The application can be completed by service providers or by referring agencies for the purposes of assessing client needs and connecting to appropriate housing opportunities.

HOUSING OPTIONS:

HousingWorks – Moore Place serves unaccompanied chronically homeless adults (no couples or families) who have a disabling condition. Chronically homeless is defined as being literally homeless – living in a shelter or on the streets – for one year or longer or four episodes of literal homelessness in the last three years. There are 85 one-bedroom efficiency apartments located in one building with 24-hour security, an on-site laundry room and a computer lab. Support services are provided on-site by a team that includes social workers, counselors, and a nurse. Social/recreational activities are arranged by the tenant services coordinator. Participation in services is encouraged but not required. Sobriety and /or compliance with a treatment plan is not required, but tenants are expected to maintain the requirements of a standard apartment lease. Income is not required at entry, but all tenants are expected to work towards obtaining a source of income once housed. Individuals with income pay 30% of their income for monthly rent. Please send referrals to:

John Yaeger

980-224-9265 (o) 980-224-9261 (f)

HousingWorks – Scattered Site serves unaccompanied chronically homeless adults (no couples or families) who have a disabling condition. Chronically homeless is defined as being literally homeless – living in a shelter or on the streets – for one year or longer or four episodes of literal homelessness in the last three years. Tenants are housed in apartments throughout Charlotte. The ability to house someone can be limited by criminal background. All tenants are assigned a case manager and other case managers provide support as necessary. Tenants may also participate in activities and resources offered at Moore Place. Participation in services is encouraged but not required. Sobriety and /or compliance with a treatment plan is not required, but tenants are expected to maintain the requirements of a standard apartment lease. Income is not required at entry, but all tenants are expected to work towards obtaining a source of income once housed. Individuals with income pay 30% of their income for monthly rent and pay for utilities. Please send referrals to:

John Yaeger

980-224-9265 (o) 980-224-9261 (f)

HUD-VASH is scattered-site housing for veterans and veteran families. Eligibility: Veteran must be eligible for medical care through VA (i.e., at least 2 years of service with Honorable, Under Honorable, or General discharge), currently experiencing homelessness (with a priority on chronically homeless, families with minor children, female veterans, and veterans who recently returned from Afghanistan or Iraq), and have case management needs. No minimum income requirement, maximum income is 30% AMI. Send referrals to:

Amanda Coker

704-310-8967 (o)

Shelter Plus Care is scattered site housing for hard to serve homeless and chronically homeless individuals and families with disabilities. Chronically homeless is defined as being literally homeless –living in the shelter or on the streets for one year or longer. Applicants with disabilities primarily include those with serious mental illness, chronic problems with alcohol and/or drugs, and HIV/AIDS or related diseases. Participant must demonstrate the ability to live independently in the community. Tenants are expected to maintain the requirements of a standard lease. Income cannot exceed very low (50% AMI) income limits. Income is not required however all participants are expected to work towards obtaining some income source through employment, entitlements, etc. Referrals are received from the agency providing the ongoing case management services to the individual/family members. Participants with income pay 30% of their income towards rent and utilities. Send referrals to:

Roxi Johnson

704-432-0075 (o) 704-319-9602 (f)

Supportive Housing Communities – McCreesh Place serves chronically homeless men who have at least one disabling condition. There are 64 single rooms with shared baths and kitchens and 27 efficiency apartments located in one building with 24-hour security, an on-site laundry room and an exercise area, community room, and computer lab. Support services are provided on-site seven days a week. Forty – fifty social and recreational activities are scheduled monthly. McCreesh Place is an alcohol and drug free community and all residents agree to random drug and alcohol screenings. Some criminal background may be a barrier. Residents are expected to pay a $75 minimum rent and the maximum income is 30% AMI. However, exceptions can be made for applicants wishing to enter without income. Tenants without income are expected to work towards obtaining a source of income once housed. Individuals with income pay 30% of their income for monthly rent. Please send referrals to:

Michelle Young

704-335-9380 (o)

Supportive Housing Communities – Scattered Site serves homeless men and women who have at least one disabling condition. Tenants are housed in apartments throughout Charlotte. All tenants are provided with support services on-site. Tenants may also participate in activities and resources offered at McCreesh Place. Sobriety and /or compliance with a treatment plan is not required, but tenants are expected to maintain the requirements of a standard apartment lease. Some criminal background may be a barrier. Income is not required at entry, but all tenants are expected to work towards obtaining a source of income once housed. Individuals with income pay 30% of their income for monthly rent and pay for utilities. Please send referrals to:

Michelle Young

704-335-9380 (o)

CHARLOTTE/MECKLENBURG COMMON APPLICATION

FOR PERMANENT SUPPORTIVE HOUSING

CONTACT INFORMATION

NAME______

STREET ADDRESS (If you are staying in a shelter or other transitional housing, please list facility name and address).

Facility Name______

Address (City, State, & Zip)______

PHONE NUMBER______GENDER______

DATE OF BIRTH (mm/dd/yyyy)______SOCIAL SECURITY #______

REFERRAL INFORMATION

Name of Referring Agency______

Name of Referring Person______

Phone Number for Referral Source______

______

APPLICANT SIGNATUREDATE

Consumer Psychosocial Information

Clinical Referral

Date: ______

Consumer Name: ______

Phone: ______Male Female

Veteran: Y N Branch: ______Years Served: ______DD214: Y N

Discharge Type: ______

Other household members applying: ______

______

Referring Clinician: ______

Agency:

Phone: ______

Email: ______

Length of time working with consumer: ______

Desired housing program(s): ____ Supportive Housing Communities - Scattered Site

_____ Supportive Housing Communities - McCreesh Place ____UMC HousingWorks - Moore Place

_____ UMC HousingWorks -Scattered Site ____ HUD-VASH ____ Shelter Plus Care

Other Housing Applications Submitted: _____ Section 8 ____ Public Housing ____ Other

Specific reason(s) consumer is applying for supportive housing:______

______

Homeless/Housing History

Currently Homeless: Y N

Current location: ______

Dates:From: ______To: ______

Previous location: ______

Dates:From: ______To: ______

Previous location: ______

Dates:From: ______To: ______

Ever been in subsidized housing? Y N

Reason for leaving: ______

______

Mental Health History

Diagnosis(es): ______

______

Receiving Treatment? ______

______

Treatment Provider: ______

______

Medications: ______

______

Substance Abuse History

Drug(s) Used: ______

Any history of problems related to use? ______

______

SA treatment history: ______

______

Last SA assessment and recommended treatment: ______

______

Any recentinvolvement in AA/NA? Y N

Medical Condition(s)

Diagnosis(es):______

______

Primary Care Provider: ______

______

Contact information: ______

______

Criminal Justice History (please include dates)

Arrest History: ______

History of felony convictions: ______

History of drug charges in a subsidized apartment: ______

Sex offender registry? ______

Currently on probation/parole? ______

Personal History

Emergency contact: ______

______

Who are the people who support you during stressful times?

______

Highest grade completed: ______Special education classes Y N

Domestic Violence Survivor: Y N

ZIP Code of last stable address: ______

Income Source: ______Amount: ______

Verification available? Y N Payee? ______

Income application pending? Y N Type: ___SS ___VA ___ Other (type): ______

Lawyer/Representative: ______

Food Stamps? Y N Amount: ______

Assets: ______

Non-cash Benefits (i.e. Food Stamps, Medicaid, VASH) : ______

Any other information? ______

______

Representative Client

______

Date Date

______

Identification and Social Security Number Verification

Applicant Name ______DOB ______

___ Attached to this form is a legible copy of a current photo ID

___ Attached to this form is a legible copy of my Social Security card OR printout from the Social Security Administration stating my Social Security Number

APPLICATION FOR SUPPORTIVE HOUSING

VERIFICATION OF DISABILITY

APPLICANT NAME:______DOB:______

To Whom It May Concern:

The individual named above is an applicant for supportive housing. Eligible applicants must have a qualifying disability verified by a licensed professional (physician, psychiatrist, RN, LCSW). By signing below, the applicant has authorized you to verify his/her disability(s). Please check as many of the criteria below as applicable to this individual and attach supporting documentation (i.e., physician progress note, comprehensive clinical assessment, etc). The information requested will be kept in the strictest confidence. Thank you for your assistance.

I authorize ______to release all information concerning my disability.

Signature of Applicant:______

1. ____ YES ____ NOThe identified person has a physical impairment that is expected to be of long-term or indefinite duration and substantially impedes his or her ability to live independently. The nature of the physical impairment is such that the person’s abilities could be improved by more suitable housing conditions.

2. ____ YES ____ NOThe identified person has a developmental 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; and reflects the person’s need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are lifelong or extended duration and are individually planned and coordinated.

3. ____ YES ____ NOIs a person with a chronic mental illness (i.e. he or she has a severe and persistent mental or emotional impairment that seriously limits his or her ability to live independently, and whose impairment could be improved by more suitable housing conditions).

4. ____ YES ____ NOIs a person who has a diagnosable substance use disorder.

Printed Name & TitleAgency/Organization

______

SignatureDate

Chronically Homeless Third Party Verification

Instructions: Please provide certification on letterhead stationery. This recommended template can be copied on letterhead or recreated with the same content on letterhead.

CERTIFICATION

I certify that ______stayed at ______

(Client’s Name) (Facility/Program Name)

during the following period(s) of time:

Between ______and ______

Additional detail about the client’s homelessness may be written below:______

Before coming to this facility the homeless person resided at ______

□ Emergency Shelter□ Mental Institution

□ Transitional Housing□ Correctional Facility

□ Permanent Housing□ Substance Abuse Facility

□ Medical Institution□ Other ______

______

(Signature of Facility Staff) (Date)

Chronically Homeless Self-Statement Certification

COMPLETE ONLY IF THIRD PARTY VERIFICATION IS UNAVAILABLE

Instructions: This template for a self-statement certification may be used when a homeless person applying to a program serving chronically homeless persons lacks connections with service providers to complete a third party verification of a history of chronic homelessness. This self-statement should be maintained in the client’s file.

I certify that I was homeless (that is sleeping in a place not meant for human habitation such as living on the streets OR living in a homeless emergency shelter during the following period(s) of time:

Between ______and ______I lived at ______

What else would you like to share about your history? For example, “I cannot remember the names of the places where I was living during the fall of 2004 but I believe that it was an emergency shelter. I have problems with my memory from that time due to an illness.”

______

I certify that the above information is correct

______

(Signature of Client) (Date)

I reviewed the above statement with the client

______

(Signature of staff witness) (Organization) (Date)

CHARLOTTE/MECKLENBURG COMMON APPLICATION

FOR PERMANENT SUPPORTIVE HOUSING

Informed Consent for Assessment and Services

Name DOB

I understand that as an applicant forPermanent Supportive Housing (PSH), I will need to complete an assessment that includes information about my past and current situations regarding health, housing, and criminal justice involvement. This information will be used to determine eligibility for several PSH programs. I understand that my information will be shared with the PSH providers that I select.

I understand that if I am selected for a PSH program, I will also be offered supportiveservices that will be provided by qualified staff. I may work with different individuals based on availability or specific skills to address my goals/needs. Services may include, but are not limited to counseling, assistance in skill building, referral to other providers, and ongoing assessment. To maintain the highest quality of care, staff will communicate with each other about my services. Communication outside of the programstaff will be limited as described in the Notice of Privacy Practices.

We are a participating agency of the Carolina Homeless Information Network (CHIN). As a member of CHIN, we use a computerized Homeless Management Information System (HMIS) to collect and report on information about the clients we serve. We collect personal information directly from you for reasons that are discussed in the CHIN Privacy Practices. We may be required to collect some personal information by law or by organizations that give us money to operate this program. Other personal information that we collect is important to run our programs, to improve services for emergency assistance, and to better understand the needs of persons needing assistance. We only collect information that we consider to be appropriate. If you do not want your information entered into and shared through the HMIS, please put an X through this paragraph.

Information collected in the Charlotte-Mecklenburg Continuum of Care’s Homeless Management Information System (HMIS) may be used for research purposes and that I am releasing my HMIS information to the University of North Carolina at Charlotte’s Urban Institute for research purposes.

If I have any questions about this consent form or about the services offered, I may discuss them with any of the case management staff. I have read and understand the information presented in this document. I consent to participate in the assessment and services offered to me. I understand that I can withdraw from services at any time.

SignatureDate