Follow application checklist (see enclosed checklist) and submit application packet with completed information and copies of requested documentation

Transcription

1 YWCA OF SALT LAKE CITY RESIDENTIAL SELF-SUFFICIENCY TRANSITIONAL HOUSING PROGRAM Application Instructions (Please read and follow carefully, then detach and keep for your records.) 1. Follow application checklist (see enclosed checklist) and submit application packet with completed information and copies of requested documentation. Submitting documentation at the beginning of the process is necessary for eligibility determination and movement through the application process. Please note: Incomplete applications will not be processed. 2. The referral source/agency must fill out and return the Agency Referral Form. The referral form may be returned to the applicant and included with the completed application or faxed directly to the YWCA by the person filling out the form. 3. Return application packet to the YWCA Receptionist. You can also mail your application to: 322 East 300 South Salt Lake City, UT or fax it to ( ) Please Write Attn: RSS Program Director 4. An interview will be scheduled with applicants who meet the basic eligibility requirements to assess if they meet the criteria for acceptance and participation. Applicants will be contacted through their home (shelter) number or work number. It will be the applicant s responsibility to return messages. Please make arrangements for child care for this interview. Applicants may be assigned additional tasks after the interview and additional documentation may be requested. Applicants will be given a deadline to return this documentation in order to keep application open and be placed on waiting list. 5. Eligible applicants will be placed on a waiting list. It is important that we have current contact information so that we can contact you when an availability is identified for you. If we are not able to contact you, your application will be closed. 6. Cancellation Policy - If you cancel your interview appointment more than two times, another interview will not be scheduled. You will need to wait 30 days and submit a new application. 7. No Show Policy - If you do not show-up for your scheduled interview, it will not be rescheduled. You will need to submit a new application after 30 days.

2 RESIDENTIAL SELF SUFFICIENCY HOUSING PROGRAM APPLICATION YWCA of Salt Lake City 322 East 300 South Salt Lake City, UT (801) The YWCA s RSS program is a 24-month transitional housing program that offers room, board, and supportive services to single women who are homeless because of domestic violence. The program provides an opportunity for residents to live in a safe, supportive environment while participating in individual case management and psycho-educational group services to work toward independence and success with independent living situations. Criteria for Acceptance and Participation: Applicant must be a recent victim of domestic violence. Applicants may be referred from other community agencies or service providers. Applicants who are self-referred must provide documentation of domestic violence. Applicant must be a female who is at least 18 years of age without primary custody of dependant children while in the program.. Applicant must be homeless due to domestic violence. Applicant cannot have been convicted of a violent felony. Applicant must have the ability and desire to become self-sufficient and end the cycle of domestic violence. Applicant must be able to occupy a single room and to share common bathroom, dining room, lounge and telephones. Applicant must be able to participate in activities of daily living without assistance as well as be able to monitor her own medication(s). The supportive services of this program DO NOT include therapy or medication management. Applicant must demonstrate ability to pay program service fee. The base fee is $300/month. This fee is re-evaluated every year and may be increased at that time. The applicant must also pay an initial $ security deposit. Applicant must be currently involved or demonstrate capability of involvement in employment, employment training, school, or volunteer work. Funding by general assistance, emergency work program or disability is acceptable as long as the resident is actively involved in a training program, school and/or seeking employment. Applicant must be able to function within a community setting, caring for herself without requiring assistance with activities of daily living or mental health services other than those provided through referral by their case manager. Applicant must also be able to responsibly monitor her own medication(s). Applicant must be free from drug or alcohol dependence and must be at least 90 days clean and sober before application. Those with a history of substance abuse must provide documentation regarding their participation in a substance abuse treatment program. Applicant must agree to comply with program rules and regulations and the YWCA mission. Applicant must demonstrate the ability to live with a diverse population of women and to respect different lifestyles and choices. Applicant must be willing and capable of actively participating in the RSS program services. Specifically, applicant must work on a self-sufficiency plan with a case manager, attend groups or therapeutic services as needed, work or go to school 20 hours per week. Applicant must complete a program application, supplying all information requested and complete an interview with program staff.

3 Residential Self-Sufficiency (RSS) Program Application Checklist In order for your application to be processed, please provide all of the following in your application packet. Be as thorough as possible, as incomplete packets will not be processed. Identifying Information: Copy of picture ID Income Verification: (*Please note that you must have some form of current income to submit an application for the RSS program.) Copy of income verification* in the form of: most recent check stubs (2) from employment or letter of employment verification stating hours, start date and pay rate from current employer or printed statement of assistance or other income General Eligibility Information: Agency Referral Form (completed by worker at referring agency) Completed RSS Program application AGENCY REFERRAL FORM

4 I hereby request and authorize the below named referral source to release information to the RSS Program pertinent to my current social, drug, medical, and psychological situation for purposes of eligibility determination. Signature of Applicant Date This portion must be completed by the worker in the applicant s referral agency. Acceptable referral sources include: shelter workers, licensed therapists, substance abuse counselors, DCFS workers, DWS workers, etc. Applicant name: (please print) Referral Agency: Agency Name Program Name Referred by: Name phone Referral Source: please answer the following questions in complete, descriptive sentences, then submit form with application or fax to (801) (ATTN: RSS Program) 1. Please describe this individual s domestic violence history and current situation: 2. Please describe this individual s current living situation: 3. What services has your agency provided this individual? 4. Please describe the individual s strengths: 5. Please describe what you believe to be the individual s weaknesses: 6. Please describe any history of drug or alcohol abuse with regard to this individual: Residential Self-Sufficiency Program Application

5 5 General Information Name Today s Date Date of Birth Current Address City State Zip Code Phone # Alternate Phone Who referred you to RSS? (This person must complete the attached agency referral form.) Name of person we can contact if you cannot be reached at the above address: Relationship Name Phone Current Address City, State Zip Code What is your primary language? Do you need an interpreter? Current Situation: What is your current living situation? YWCA Battered Women's Shelter Rental housing. If so, are you currently being evicted? [ Other Shelter: name of shelter Living on the street (i.e. in a car, park, sidewalk, abandoned building Transitional Housing Program: name of program ] yes [ ] no Mental Health or Substance abuse treatment facility Living with an abusive partner Other. Please explain Please explain the most recent incident of Domestic Violence, along with approximate dates: Name of abuser First Name Last Name Relationship Current Whereabouts What is your total monthly income? $ What is your current source(s) of income?

6 6 Wages/Salary General Assistance Unemployment SSI SSDI Other: Do you currently have the ability to pay the deposit and the first month s fee? (fee will be pro-rated based on the day of move-in) [ ]Yes [ ]No Are you currently employed? [ ] yes [ ] no Please list current employment situation below: 1. Employer: Position Held: Length of Employment: Address: Supervisor: Phone: Are you willing and able to work, attend school or job training, or volunteer while you participate in this program to increase your self-sufficiency? [ ] yes [ ] no Please list any arrests/convictions, along with dates, that will appear on your criminal history/background report. (You may be required to submit court papers or police reports.) Physical/Mental Health Information Do you have physical or mental health conditions that trouble you chronically? [ ] yes [ ] no If yes, please explain: Current Medication(s) (include name of medication, what it is prescribed for and how often it is taken): MEDICATION PRESCRIBED FOR FREQUENCY OF USE Are you currently seeing a counselor/therapist? [ ] yes [ ] no Therapist/Agency Name Address Phone Have you had any history of hospitalizations for physical/mental illness (other than childbirth)? [ ] yes [ ] no If yes, please explain: