Independent Living Initiative Program

Independent Living Initiative Program

Risk/barrier factor checklist

Instructions

This checklist is a summary of the risk/barrier factors often associated with obtaining and maintaining housing. Determining which risk factors are present will help housing triage committee members prioritize ILIapplications and appropriately disburse resources. Please ensure risk/barrier checked corresponds with information presented in application. Please only check only one risk/barrier factor in the category unless otherwise noted.

The Housing Triage Committee will calculate the score for each applicant based on the risk/barriers checked. The maximum of amount of assistance for and individual/household is 3 months based on their risk/barrier factors. No extensions will be granted after the individual/household’s assistance period ends.

Please complete this form and submit to , ,

Name of Applicant: ______

Check all that apply /  / Additional Comments
Service use / At least 3Frequent hospitalizations (health, psychiatric, inpatient treatment program) or jail stays in past year
Involved with at least 3service systems (i.e. DSS, Criminal Justice System, Public Health, Mental Health)
At least 2 hospitalizations or jail stays in the past year
Involved with at least 2 service system (i.e. DSS, Criminal Justice System, Public Health, Mental Health)
Only Involved with Mental Health System
Education / No high school diploma or GED/language is a barrier
Enrolled in literacy and/or GED program and/or has sufficient command of English to where language is not a barrier to employment
Has high school diploma/GED and needs additional education/training to improve employment situation and/or to resolve literacy problems to where they are able to function effectively in society
Has high school diploma/GED; no additional training needed
Has completed education/training needed to become employable
Social/Family Support / Lack of necessary support from family or friends/abuse (DV/Child) is present or there is child neglect
Family/friends may be supportive but lack ability or resources to help; family members do not relate well with one another; potential for abuse or neglect
Some support from family/friends; family members acknowledge and seek to change negative behaviors/are learning to communicate and support
Strong support from family or friends. Household members support each other’s efforts
Strong/health support from family or friends and expanding support network
Criminal Justice Involvement / Critical Felony History (i.e. sexual offenses, murder, arson, maintaining/dwelling illegal substances) or Illegal drug activity within the last five years.
Released from jail or prison within last 30 days. Current charge(s)/trial pending, noncompliance with probation/parole, but no illegal drug-related activity in the last five years.
Fully compliant with probation/parole terms or history of multiple misdemeanors
Has successfully completed probation/parole within past 12 months, no felony criminal history, and no active criminal justice involvement
No criminal history
Housing Concerns / Homeless or has received written eviction notice or rent burden at 66%-80% of income, ineligible for public housing
In transitional, temporary(living with family or friends/couch surfing; doubled-up), or substandard housing and/or current rent/mortgage payment is unaffordable (over 50% of income)
In stable housing that is safe but only marginally adequate
Household is in safe, adequate subsidized housing (i.e. public housing, section 8, permanent supportive housing)
Household is in stable, safe, adequate, unsubsidized housing
Income / No income
Inadequate income and/or spontaneous or inappropriate spending
Can meet basic needs with public benefits/assistance; appropriate spending
Can meet basic needs and manage debt without assistance
Income is sufficient, well managed; has discretionary income and is able to save.
Employment / No employment and no significant employment history
Unemployed but with positive/significant employment history
Temporary, part-time, or seasonal employment; inadequate pay
Employed full time; inadequate pay
Employed with full time with adequate pay and benefits
Health Care Concerns / Aged 60+and/or life threatening illness (i.e. end stage renal disease, HIV/AIDS)
Tri-morbidity: co-occurring psychiatric, substance abuse, and chronic medical condition
Co-morbidity: psychiatric and chronic medical condition or substance abuse and chronic medical condition
At least one chronic medical condition
Time limited illness/condition (i.e. pregnancy); no substance use/alcohol abuse in last 6 months, no health issues
Risk Exposure (check all that apply) / History of domestic violence
History of multiple evictions ( 3 or more in last 3 years)
Has not rented housing in the past or negative rental history
Has at least one child age 0-6
Head of Household under 24 years old or was in foster care
Household needs 3 or more BR unit
Single parent household

Revised 10-2013