The Valor House and Housing Montana Heroes

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1 The Valor House and Housing Montana Heroes Application Information The Valor House and Housing MT Heroes are transitional housing programs for homeless veterans whose goal is working towards stable housing. Both programs seek to assist homeless veterans in need, including elderly, disabled, and Native American veterans, and those coping with mental illness and substance abuse. Participating residents will identify personal goals focusing on housing and stability; increasing skills and income; and improving self-determination. Valor House 2820 Great Northern Loop Missoula, MT Tel. (406) , Fax (406) The two programs Housing MT Heroes 1110 W. Broadway Missoula, MT Tel. (406) , Fax (406) Located at 2820 Great Northern Loop 17 single occupancy apartment units, including a full kitchen and private bathroom Veterans provide their own meals Rent is 30% of income 2 laundry rooms 2 TV areas 5 community computers Housing Choice Voucher eligible after 12 months in program Guests allowed, with approval A collaborative project between the Poverello Center, the VA and Missoula Housing Authority Located at The Poverello Center Semi-private rooms, reserved for 26 eligible veterans in a separate wing of the building 3-meals per day provided Rent is FREE Laundry room Community room with TV for program participants Two community computers A collaboration between The Poverello Center and the VA SIMILARITIES between Valor House and Housing MT Heroes On-site case managers and 24-hour staffing Individualized assessments and goal planning with referrals to other social services A supportive, sober living environment No one may enroll in one of these programs and remain on the wait list for the other Transferring between programs is not permitted Secure and separate space for female veterans Program Requirements for both programs: Participate in case management and make progress toward independent housing No alcohol or drug use on or off property Maintaining the ability to self-administer prescribed medications and manage daily activities of independent living Leave must be approved by case manager Sign in and out, chores, and room/apartment inspections Volunteering, work, and/or education activities Veterans may apply for Valor House and/or HMtH using the following single application. The application may be submitted to either program location. 11/19/2014 Page 1 of 6

2 By signing and dating below, you acknowledge that you have read and understood program expectations and any information provided within the screening form is accurate to the best of your knowledge. Applicant s printed name: Applicant s signature: Date: Submit this Application: Completed applications can be returned to Valor House OR The Poverello Center, ATTN: Housing MT Heroes/Valor House by mail, fax, or in person (see address information above). Applications are reviewed in the order received. If you have any questions regarding the program or the application process, please contact Valor House at or The Poverello Center at (406) Application for: (check one or both) Valor House Housing MT Heroes Initial Screening Form Individuals interested in residing at Housing MT Heroes or Valor House will be expected to provide information necessary to identify needs and goals which will facilitate the screening process. Any questions regarding the application process should be directed to the Housing MT Heroes Case Manager or the Valor House Program Manager. Name: Contact Number(s): Mailing Address: (not for confidential communications): DOB: SSN: Race: Tribal Affiliation: Referring Provider or Contact Agency: _Number: Goals Please list some goals and objectives you plan to address while residing in transitional housing: /19/2014 Page 2 of 6

3 Military Service PLEASE LIST RECORD OF MILITARY SERVICE Branch Dates of Service Discharge Type Do you have a copy of your DD214? Yes No Housing Where did you sleep last night? Place not meant for habitation (outside, tent, vehicle, etc.) Emergency shelter With friends or family Mental health/substance abuse treatment facility Prison, jail, or pre-release facility Hotel or motel Other (explain): Have you been in a Housing Program for Veterans before? Yes No Location Date(s) Discharge Type list a record of enrollments: Along with the Housing MT Heroes and Valor House programs, other supportive housing programs are available within the Missoula Area. Please indicate below if you are currently on the waiting list of any programs identified (please check all that apply): HUD-VASH Housing Choice (Section 8) Voucher Shelter + Care Treatment Program(s) 11/19/2014 Page 3 of 6

4 Health Are you currently enrolled in the Montana VA Healthcare system? Yes No If Yes: Name of your Primary Provider: If No, please list your non-va primary care provider(s): Have you been enrolled in VA Healthcare in a state other than Montana? Yes No list which states: Are you currently disabled? Yes No Do you require any reasonable accommodation? Yes No explain accommodation(s) needed: Are you currently receiving disability benefits? Yes No N/A If No, are you applying for disability benefits? Yes No Do you have any medical problems? Yes No list any problems or conditions: Do you have any mental health issues? Yes No list any issues or conditions: Are you currently taking any medications? Yes No list medications: Have you been addicted to or misused drugs or alcohol? Yes No If Yes, identify issues with drugs or alcohol: 11/19/2014 Page 4 of 6

5 Are you currently attending support groups? Yes No identify group and list attendance frequency: Income and Employment Please list any sources of income you are currently receiving: Income Source Amount _ Are you currently employed? Yes No If Yes, monthly income:_ Have you been employed in the past 12 months? Yes No Do you have any outstanding debts (including out of state)? Yes No list current debts (child support, court fees, etc.): Debt _ Amount LegaI Issues Have you been incarcerated in the past two years? Yes No list: Date(s) Reason 11/19/2014 Page 5 of 6

6 Are you currently required to register as a violent offender? Yes No Are you currently required to register as a sexual offender? Yes No Are you currently on probation or parole? Yes No list Probation/Parole Officer(s): Do you have any pending legal issues? Yes No identify legal issues: Transportation Do you have a valid driver s license? Yes No Do you have reliable transportation? Yes No If Yes, identify mode of transportation: Do you have any barriers to transportation? Yes No identify barriers: Strengths and Supports Do you have people or places in your life that support you in meeting your goals? Yes No list some of your supports: If No, what kinds of supports could help you meet your goals? 11/19/2014 Page 6 of 6 Thank you for your application. We will contact you shortly.