Independent Living Initiative Application

Independent Living Initiative Application

Cumberland Durham Johnston Wake

Today’s Date: [Date]
Type of Assistance (attach eviction notice, utility notice/statement, letter of intent to rent)
Name of Landlord/ utility company (must be included):
Mailing Address (must be included):
Rental Assistance Monthly Amount $
Security Deposit Amount $
Utility Assistance Amount $
Total Amount of request:______/ Reason for referral:
Startup cost: Rental Deposit Prevention: eviction
Startup cost: Utility Deposit Prevention: utility disconnection
Startup cost: 1st month rent
Assistance with transition (i.e. from institutional setting, shelter):
1 month 2 months 3 months

Referral Information

Referral Source (name/title of person) Name and Phone of Agency:
Email Address: QP contact phone number: ( )

Demographics

Head of Household: / Assessment Date:
Date of Birth _____/______/______Gender: Male Female
Home Phone: / Cell Phone: Business Phone:
Email: / Emergency Contact:
Family Status: Single Couple Family (must include at least one child under the age of 18)
Has any household member ever served in the military?
Yes No / Please list all other household members:
Name/Relationship Date of Birth
CURRENT Address: City: Zip
CURRENT Housing: Type of Housing:
Permanent Group Home
Supportive Housing Program Foster Care Home (DSS)
Transitional Housing Program Institution (jail, detention, hospital, prison, PRTF)
Recovery/Halfway house (long term) Boarding/Rooming house or other unlicensed facility
Family/Friend (temporary, not on a lease, couch surfing) Public Housing/Housing Choice Voucher Program (Section 8)
If Homeless, please specify:
Street campsitecar Emergency Shelter Transitional Shelter Domestic Violence Shelter If at a shelter how long? ______
Substance Abuse Treatment Program Hotel/ Motel Voucher from______other:______
CURRENT Housing Stability:
Stable (safe, adequate, affordable housing and is the appropriate level of care for the individual)
Unstable, specify: facing eviction insufficient income unsafe living condition
homeless inappropriate level of care need for transition

Mental Health & Institutional Information

Name of person (s) receiving MH/IDD/SA services: / Type of Services:
Was any household member admitted to the hospital or local crisis facility for psychiatric, substance abuse, and/or medical care in the last year? Yes, how many times______No / Household Member Name:

Medical Care

Does the participant have a primary care physician? Yes or No / Is the participant able to access medication? Yes or No
Please describe any relevant medical conditions that impair individual’s functional capacity:

Criminal Justice Involvement

Has any household member ever been convicted of a crime?
Yes or No / If yes, please explain
Has any household member been incarcerated in the last year? Yes, how many times______No
Does anyone have pending charges Yes, Please explain______No
Is he/she involved with the criminal justice system or the courts? Yes or No / Is any household member currently on probation/parole?
Yes or NoIf yes, please give the name of the officer and/or court counselor and contact information:

DSS Involvement

Has the participant had involvement with CPS in the past year?
Yes, describe:
No / Is the participant currently involved with CPS?
Yes, describe:
No

Income Information

Current household gross monthly income:
Employment _$______Retirement _$______Work First _$______
Public Benefits _$______Unemployment _$______Subsidized Childcare_$______
SSI _$______Veteran Benefits_$______Food Stamps_$______
SDDI _$______Other _$______
Child Support _$______
Length of employment: ______Years ______Months
If receiving unemployment, when does the assistance terminate? _____/______/______
Disability Benefits
If not currently receiving SSI/SSDI has individual applied? Yes No N/A Date of Application:______
Status? 1st application Pending Reconsideration Appeal SOAR Application Process
Medicaid Status
If not currently receiving Medicaid has individual applied? Yes No N/A Date of Application:______
Status? 1st application Pending Reconsideration Appeal

Educational and Vocational Information

Highest Grade completed:______Currently enrolled in school: Yes No If applicable, name of school:______
Currently job seeking: Yes No N/A
Has consumer had any job interviews? Yes No
Enrolled in job skills program: Yes No N/A If yes, which program is consumer attending? ______
Enrolled in VR services? Yes No N/A
Volunteer/day program? Yes No N/A

hOMELESS pREVENTION/rEHOUSING sERVICES

Has client received Financial Assistance in the last 2 years? (Includes rent, utility and move-in)? Yes No
If “yes”, please indicate what agency provided assistance:
Type of assistance provided:
Rental assistance Moving cost Eviction prevention Rapid re-housing
Security deposit Utility assistance Motel voucher Other
Amount of Assistance client can pay using other resources - $ / How long has client resided at current address:
______Years ______Months
What is the current monthly rent amount? / What is the total amount owed?
If seeking utility assistance, does the client have a shut-off notice? Yes or No / Does client need utility assistance due to relocation? yes or No
Does client need utility assistance due to disconnection of services Yes or No / Would the client household be homeless but for ILI assistance?
Yes or No Why?

Eviction Information

Is there a formal eviction notice (i.e. 10 day notice) Yes or No / Have you received other eviction notices in the last five years? Yes or No
If Yes, how many?
What is the reason that led to the current eviction? / Is the landlord/property management willing to accept payment? Yes or No
Does client have a legal notice/demand letter? Yes or No
Vacate date ___/____/____ / Attorney information (if applicable):

Sustainability (application will not be processed if this section is not completed thoroughly)

Characteristics for Household’s ability/potential to sustain housing after subsidy is terminated (Mark all that apply):
Employment Employability/Strong work history Dual parent household
Evidence of increased income Evidence of approval for housing subsidy (Section 8, HUD VASH) Other:
Please explain sustainability plan:
Please include detailed information supporting the need for assistance (i.e. describe the specific housing needs of this consumer, what events occurred to cause the housing/utility crisis):
Please explain (in detail) the plan for sustaining housing after ILI funds are no longer supporting housing:

Vendor Information

Legal Name of Vendor: (ex. Landlord/Utility Company) / Contact person:
Payment payable to: / Mailing address:
Account:
Email address:
Phone number:

Applicant Certification:

I______, request one time assistance from Alliance Behavioral Healthcare to help pay for the housing related expense(s) listed above. I understand that providing false information on this application may result in denial or termination of assistance. As an applicant for the Alliance Behavioral Healthcare Independent Living Initiative Program, I certify that all of the above information is true, and I authorize the Alliance housing specialist to verify all information in this application and housing review committee to review this application to determine eligibility and level of assistance.

______

Head of Household SignatureDate

Provider Certification:

By signing below, you agree:

1)That the information in this packet is correct to the best of your knowledge.

2)That you understand and will comply with documentation expectations for this consumer.

3)That you understand and will comply with request for information concerning consumers housing status at intervals of 3 and 6 months if financial assistance is provided.

4)That should this consumer disengage from services with you and/or your agency you will comply with requirements and contact Alliance Behavioral Healthcare housing specialist of the change.

______

Professional Service Provider SignatureDate

Application Checklist

Signed and dated applicant and Provider Service Agreement

Income Verification(paystubs, award letter dated within 120 days of application, etc.)

Copy of oneIdentification Document (Birth Certificate, Social Security Card, Picture I.D., etc.)

Intent to rent(approval letter from landlord/property manager) if applicable

Utility Verification(statement of obligation, disconnect notice) if applicable

Eviction notice and lease

If back rent is due we will require a written agreement between you and your landlord that specifies a payment plan. This ensures that you will not be evicted.