Referral to the Ruth House

Referral to the Ruth House

Name: ______Date: ______

Social Security Number: ______DOB: ______

Race: Caucasian ___ African-American ___ Asian ___ American Indian ___

Ethnicity: Hispanic ___ Non-Hispanic ___

Phone Numbers: (H) ______(W) ______(C) ______

Previous Last Names (maiden or formerly married): ______

Current Address: ______

If currently in residential treatment, what is expected discharge date:______

Previous Address:______

Other states you have resided in: ______

Any income received in the last 30 days? Yes No

Are you homeless? (Due to what reason)______

Using History

Are you addicted to drugs or alcohol? Yes ___ No ___

List substances you used: ______

Sobriety Date: ______

Date you went to your first AA/NA Meeting? ______

How many meetings do you attend per week? ______

Where’s your home group? ______

Please contact YWCA La Crosse Housing Case Manager, Teresa Silcox, with any questions. Phone: 608.782-0706 Fax: 608.781-2906

3219 Commerce Street, La Crosse, WI 54603 1

Other Support Systems: ______

Names and Phone Numbers for:

Family member who is supportive: ______

Address: ______

______

Emergency contact person: ______

Sponsor: ______

Probation/Parole Officer: ______

Drug/OWI Court Representative: ______

Social Worker: ______Agency: ______

Counselor: ______Agency: ______

Attorney/Public Defender: ______

Psychiatrist: ______Hospital: ______

Medical/Mental Health History

List all current Diagnoses: ______

______

Current Medications:

Medication: ______Dose ______

Please contact YWCA La Crosse Housing Case Manager, Teresa Silcox, with any questions. Phone: 608.782-0706 Fax: 608.781-2906

3219 Commerce Street, La Crosse, WI 54603 2

Medication: ______Dose ______

Name of Pharmacy: ______

AODA Treatment dates (List all): ______

______

Name of Treatment Centers and addresses/ phone # (last five years): ______

______

Are you on Disability? Yes ___ No ___ Date began: ______

Amount: ______

Are you a party in a restraining order? Yes ___ No ___

Are you now or have you recently gone through a divorce or separation? Yes ___ No ___

Employment History

Are you currently employed? Yes ___ No ___

Name/Address of employer: ______

______

Number of hours you work per week: ______

Please contact YWCA La Crosse Housing Case Manager, Teresa Silcox, with any questions. Phone: 608.782-0706 Fax: 608.781-2906

3219 Commerce Street, La Crosse, WI 54603

Shift: ______

Wage: ______

Contact person at work: ______

If you are not employed are you looking for work? Yes ___ No ___

Total monthly income: ______

List all Sources of income: ______

______

List Criminal History and state of jurisdiction: ______

______

I certify that the information on this application is correct to the best of my knowledge.

I understand that any misrepresentation or false information provided on this application is reason for the application to be rejected.

I give YWCA La Crosse Ruth House staff permission to verify all information on this application with the appropriate organizations and agencies. All medical information is exempt from this release of information and a separate ROI will be signed for any medical information.

______

Signed Date

______

Witness Date

Please contact YWCA La Crosse Housing Case Manager, Teresa Silcox, with any questions. Phone: 608.782-0706 Fax: 608.781-2906

3219 Commerce Street, La Crosse, WI 54603 4

Wisconsin ServicePoint (WISP) Release of Information

When you request or receive services from YWCA La Crosse, we collect information about you and your household and enter it into a computer program called Wisconsin ServicePoint (WISP). This program helps us to better understand homelessness, to improve service delivery to the homeless, and to evaluate the effectiveness of services provided to the homeless. WISP is used by over a hundred social service agencies throughout the state that provide services to homeless and low-income persons.

What information is collected? Depending on your situation, you may be asked for some or all of the following:

• Basic identifying information (may include name, SSN, date of birth, gender, race, marital and family status, household relationships, phone numbers, military veteran status, whether or not you have a disability)

• Housing information (may include address, type of housing, homeless status, reason for homelessness)

• Income information (sources and amounts of household income, employment information, work skills)

• Legal history/information

• Medical information

• Services needed and provided; outcomes of services provided

What happens to the information collected?

• Details of your medical/health status will never be shared between agencies using Wisconsin ServicePoint.

• With your approval, information collected is shared with other service agencies, but only with authorized persons at these agencies.

• Collectively, data on the homeless population in Wisconsin (but not personal identifying information ) is used in statewide reports on homelessness

NOTE: WISP uses many security protections to ensure confidentiality and only agencies that use WISP can access this program.

Why should you agree to have your information shared with other agencies that use Wisconsin ServicePoint?

By sharing your information with these agencies, you will help them:

• Identify other services or programs you may be eligible for,

• Better coordinate services for you and your household,

• More accurately count the number of homeless persons, services available and services needed,

• Show the people who fund homeless programs that the services are needed and

• Obtain other funding for programs that serve homeless persons.

CLIENT INFORMED CONSENT/RELEASE OF INFORMATION AUTHORIZATION

You have the option to restrict access to personal information that you are providing about yourself and your minor children. You may modify this consent with respect to the sharing of your information at any time.

Except for medical/health status information, you have my consent to share all other information about me with other WI ServicePoint agencies in Wisconsin unless specified otherwise below.

□ All Information, except the following, may be shared with authorized personnel in other service agencies in

Wisconsin:______

□ My information should not be shared with the following program/agencies:

______

□ My information may only be shared with authorized personnel in the following program/agencies:

______

□Information about me may only be shared with authorized personnel within this agency.

Your release of information authorization is valid for three (3) years from the date of this document. You may cancel this authorization at any time by written request, but the cancellation will not be retroactive.

SIGNATURE OF CLIENT OR GUARDIAN DATE SIGNATURE OF AGENCY WITNESS DATE

Please contact YWCA La Crosse Housing Case Manager, Teresa Silcox, with any questions. Phone: 608.782-0706 Fax: 608.781-2906

3219 Commerce Street, La Crosse, WI 54603