NEIGHBORHOOD HOUSE HOMELESS PROGRAM

HOW TO REFER A FAMILY (FY 15-16)

Thank you for your interest in referring a family to our homeless program. Please complete the following information with the family you have in mind. By making this referral you are stating you have known the family long enough to know they would be a good fit for the program.

Answer all questions to the best of your ability. Do not leave blank spaces. Incomplete applications will not be accepted.

The form must be emailed to

The process will be as follows:

  1. Completed referrals will be evaluated for eligibility on a first come first serve basis.
  2. You will receive an automatic reply once the email with the referral has been received. Follow up emails will be received with status updates.
  3. Due to the limited funding and vacancy rates in our program, applications will only be accepted as openings occur. Please call 503-246-1663 x 5200 for opening updates
  4. Please do not have the families contact us directly until their name has come up for an assessment. When the family’s name has come up for an assessment, the referring person will be contacted and they will have 3 days to schedule the first appointment.
  5. If contact isn’t made within 3 days, NH will move on to the next family referral.

Please take into consideration that we offer a complete program and the family being referred must be ready for change.

Only homeless families(HUD definition) may be referred.

Referrals will automatically be denied for the following reasons: no children or verifiable pregnancy, violent offenses, registered sex offenders, convicted of manufacture and/or delivery of a controlled substance, have an open warrant, have more than $5,000 in landlord debt, or are in need of a safe house.

Giving false information will result in the immediate denial of the application.

Please keep the top page as a reference

TRANISITONAL HOUSING REFERRAL FORM

(TO BE COMPLETED BY REFERRING AGENCY)

PLEASE PRINT LEGIBLY / DO NOT LEAVE BLANK LINES

Name of referring case worker/person: ______

Agency name: ______Phone #: ______

Position: ______Fax #: ______

Email address:______

Family being referred: ______

How long have you known this family? ______

How did you begin working with this family? ______

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What services are you currently providing for this family? ______

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What services will you continue providing after placement into program? ______

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Are you able to participate in joint meetings with the family and our staff to coordinate services and case planning? ( ) YES ( ) NO

What have you observed the family strengths to be? ______

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In your opinion, why do you feel the family will be appropriate for our homeless program? ______

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What goals do you feel the family should work towards while in the program? ______

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What concerns do you have with this family? ______

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Additional comments: ______

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Checklist:All items must be submitted together otherwise the referral cannot be accepted.

☐ All questions complete

☐Release of Information to Neighborhood House (this is your agency form)

☐Verification of homelessness

Please mark the program that you are referring your family too. Please mark only one program. Complete additional referral forms if you would like to refer the family to additional programs. As a reminder referrals will only be accepted if there are current vacancies.

☐Turning Point

-I understand the apartments are small one bedroom efficiencies and are located in SW Portland

-I understand that the program consists of intensive case management focused on increasing income, gaining self-sufficiency, and securing permanent housing

-The family must be in the following situation:

  • Living on the streets, or place not meant for human habitation
  • Staying in a motel paid by an agency
  • Staying in an emergency shelter
  • Fleeing domestic violence
  • Couch surfing does not meet the eligibility for this program

-I understand that the family will pay 30% of their adjusted gross income to rent

-If no minor dependent child(ren) are in the family’s physical custody, the family will provide a letter from DHS child welfare/relevant party stating that custody will be returned within 14 days of program or a statement verifying pregnancy from a primary care physician.

-Average length of stay will be 12 to 18 months

☐Scattered Site

-The family has physical custody of a minor dependent child or has a verifiable pregnancy

-The family must be in the following situation:

  • Living on the streets, or place not meant for human habitation
  • Staying in a motel paid by an agency
  • Staying in an emergency shelter
  • Fleeing domestic violence
  • Couch surfing does not meet the eligibility for this program

-I understand the family will pay up to 30% of their adjusted gross income

-I understand the family must be able to be approved in a private rental unit in Multnomah County and have a realistic plan to sustain the unit after the program ends.

-The program length of stay will average 6 months to 12 months

☐ Chase House

-I understand this program is for single mothers with a child not yet school age

-I understand that families will be sharing a 5 bedroom house located in North Portland

-I understand the family must pay rent in the amount of $350 to $400 per month and a security deposit equal to one months rent.

-The program length is 1 year

By signing this referral form, I understand that the information is true to the best of my knowledge. I am recommending the family to the homeless program and I believe they will make the necessary changes to improve their homeless situation.

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SignatureDate

TO BE COMPLETED BY FAMILY

PLEASE PRINT LEGIBLY / ANSWER ALL QUESTIONS

Name/ head of household: ______

Date of birth: ______Age: ______

Please list all family members who will move into the household immediately

Name: ______

Relationship: ______Date of birth: ______Age: ______

Name: ______

Relationship: ______Date of birth: ______Age: ______

Name: ______

Relationship: ______Date of birth: ______Age: ______

Name: ______

Relationship: ______Date of birth: ______Age: ______

Name: ______

Relationship: ______Date of birth: ______Age: ______

Please list all family members who will move into the household at a later date

Name: ______

Relationship: ______Date of birth: ______Age: ______

Reason for moving in later: ______

Name: ______

Relationship: ______Date of birth: ______Age: ______

Reason for moving in later: ______

When did you become homeless (approximate date)? ______

Please check where you are currently residing?

( ) Emergency Shelter ( ) Hotel being paid for by an agency ( ) On the streets

( ) Institution: how long have you been residing there? ______

( ) Being evicted through the courts

( ) Fleeing Domestic Violence ( ) Residing with Friends/Family

How did you initially become homeless? ______

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Is this the first time you have experienced homelessness? ( ) YES ( ) NO

If not, how many times have you experienced homeless in the past? ______

Please explain those circumstances? ______

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What has prevented you from renting your own home? ______

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Do you have any evictions on your record? ( ) YES ( ) NO

**Not eligible for program if more than 3 evictions or owe more than $5,000 in landlord debt**

Date: ______Address: ______

Reason for eviction: ______

Amount owed to landlord: $ ______

Date: ______Address: ______

Reason for eviction: ______

Amount owed to landlord: $ ______

What steps have you taken to overcome your homelessness? ______

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Are you on any affordable housing waitlists in the area? Please list: ______

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Source of income:______$ ______

______$ ______

______$ ______

Food stamps$ ______

Please list any criminal charges:

**Not eligible for program with violent offenses, are a registered sex offender, and/or convicted in manufacture and/or delivery of a controlled substance, or have an open warrant**

Name: ______Date: ______

Charge: ______Disposition: ______

Name: ______Date: ______

Charge: ______Disposition: ______

Name: ______Date: ______

Charge: ______Disposition: ______

Please complete the following chart so that we know what other agencies you are receiving services from:

TANF

Worker: ______Phone: ______

DHS (Child Services)

Worker: ______Phone: ______

Parole/Probation

Worker: ______Phone: ______

DV Counselor

Worker: ______Phone: ______

A&D Counselor

Worker: ______Phone: ______

Please explain in your own words what you hope to gain from participating in our homeless program. If self-sufficiency is your goal, please describe what that looks like to you.

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Please list a few primary goals you would like to work on while in the program:

  1. ______
  1. ______
  1. ______

I understand that by signing this form I/we are giving permission to the referring agency to disclose information to Neighborhood House that would help with placement into one of the housing programs. I/we have completed this form to the best of my/our ability and all information is true to the best of my/our knowledge. I/we understand that knowingly providing false information will result in denial of any further consideration.

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Head of household signatureDate

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Other adult signatureDate

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