Homeless to Home - Information

Transcription

1 Homeless to Home - Information Homeless to Home (H2H) is a rapid re-housing program serving individuals and families who reside in Seminole County. For those that qualify for H2H, we provide rental assistance, one-time utility assistance, and job training assistance. To help meet any additional needs of our clients, we also partner with agencies such as Seminole Behavioral Healthcare, Goodwill Industries, and Safehouse of Seminole. The purpose of this program is to successfully return households to economic self-sufficiency and stable housing. Initial eligibility requirements 1. Must make at or less than 50% of the Area Median Income by household size ,500 23,400 26,350 29,250 31,600 33,950 36,300 38, Must meet the homeless criteria as defined by the Hearth Act. For example: Living on the streets, in a car, at a train/bus station, places not meant for human habitation Living in a shelter or transitional housing program Living in a weekly hotel/motel Living with friends or family where there is no extra living space (doubled up, couch surfing) Being evicted or asked to leave current residence, within 14 days, and do not have the resources to obtain housing Fleeing domestic violence with no alternative housing option 3. Must be a Seminole County resident 4. Must be able to remain self-sufficient once assistance ends The process is as follows: 1. Application H2H staff will review the application and if you meet the initial eligibility guidelines, you will be contacted for an interview. 2. Interview H2H staff will review all supporting documentation and complete a needs assessment for a full understanding of household needs. An interview does not guarantee program approval. 3. Approval or denial a. If the applicant is denied, H2H will provide referrals and resources for other agencies that can best serve their situation. b. If the applicant is approved, H2H staff will provide specific steps that need to take place for the easiest and quickest transition into housing. You can find more information about Homeless to Home on our website: You can drop the application off at HTI, fax it to , or it to stacy@harvesttime.org

2 Client ID#: Homeless to Home - Client Application (one application per adult) Date: First Name: Last Name: Male Female SS#: DOB: Marital Status: Address: City: County: Zip: Phone #: address: Ethnicity (must choose one): Race (choose all that apply): Hispanic White American Indian or Alaskan Native Asian Non-Hispanic Black Native Hawaiian or Pacific Islander Multi-racial (3 or more races) Partner/Spouse name: M F DOB: Race: Ethnicity: History of Homelessness Have you ever been homeless before? Yes No How long have you been homeless on this occasion? From / / to / / Resided at: City: From / / to / / Resided at: City: Where did you stay last night? Place not meant for human habitation (car, abandoned building, bus/train station, airport, or outside) Rental, no subsidy Rental, with VASH subsidy Rental, with other subsidy Living with a friend Living with a family member Hotel/motel paid for with own funds Own home, no subsidy Owned home, with subsidy Foster care or foster group home Emergency shelter, including hotel/motel paid for with voucher Transitional housing program Permanent housing for formerly homeless Psychiatric hospital/facility Substance abuse treatment center Hospital, non-psychiatric Jail/prison Safe Haven Other: How long have you been there? 1 week or less 1 week to 1 month 1 to 3 months 3 months to 1 year 1 year or longer Are you chronically homeless? Yes No Criteria for chronically homeless: 1) Has a disabling condition 2) Either continuously homeless for more than 1 year OR has had 4 episodes of homelessness in past 3 yrs. Last permanent address: Where did you last have a home (room/apartment/house) of your own for at least 3 months? City: State: Zip:

3 Housing History (begin with the most recent and provide a minimum three-year history) Previous address: Monthly rent: $ From: / / to / / Was your name on the lease? Yes No Reason for leaving: Lease outcome: Completed Left early, no eviction Damages outstanding Evicted Previous address: Monthly rent: $ From: / / to / / Was your name on the lease? Yes No Reason for leaving: Lease outcome: Completed Left early, no eviction Damages outstanding Evicted Previous address: Monthly rent: $ From: / / to / / Was your name on the lease? Yes No Reason for leaving: Lease outcome: Completed Left early, no eviction Damages outstanding Evicted How many times have you been evicted? If you have had evictions, please list the details below: Property name: City/State: Balance owed: Property name: City/State: Balance owed: Employment History (begin with the most recent and provide a minimum of your past 5 jobs) If you are currently unemployed, please briefly describe the reason and length of time unemployed:

4 Current monthly income: Income source Amount Employment Income (Client A) $ Employment Income (Client B) $ Unemployment $ SSI $ SSDI $ Veteran s Disability $ Worker s Compensation $ Temporary Assistance for Needy Families (TANF) $ Retirement Income from Social Security $ Veteran s Pension $ Child Support $ Alimony $ Other source: $ Total monthly income: $ Current non-cash benefit amount: Non-cash benefit source Receiving benefit? Supplemental Nutrition Assistance Program (SNAP, food stamps) Yes No If yes, amount: $ MEDICAID Yes No MEDICARE Yes No State Children s Health Insurance Program Yes No WIC Yes No Veteran s Administration Medical Services Yes No TANF Child Care Services Yes No TANF Transportation Services Yes No Other TANF-funded services Yes No Section 8, public housing, other rental assistance Yes No Other Yes No Asset Information and Credit History - List the type and source of any family assets. Type of Asset Full Name of Account Holder (savings, investments, etc) Cash Value Annual Income from Asset Do you have a bank account? Yes No If yes, what type of account? Have you ever filed for bankruptcy? Yes No If yes, when? / / Have you ever had a home foreclosed on? Yes No If yes, when? / / Do you have student loans? Yes No Do you have excessive debt? Yes No

5 Educational History Highest Level of Education Completed: GED H.S. Diploma Some College 2 yr. Degree 4 yr. Degree Masters Doctorate If no high school diploma, what is the highest grade level you have completed? Are you currently a student? Yes No Enrollment status: Full Time Part Time If yes, where are you attending? Other Vocational or Academic Education: Certificates or Licenses Held: Special Education Needs: Learning Difficulties: ADHD ADD Dyslexia Other: Legal History Number of times arrested: Are you currently serving parole or probation? Yes No Time left on probation or parole: Misdemeanor convictions: Felony convictions: Are you currently involved in any lawsuits? Yes No Please specify: Do you have any charges pending or are you awaiting trial? Yes No Please specify: Have you ever been the victim of domestic violence? Yes No If so, when did it occur? in the past 3 months 3 to 6 months ago 6-12 months ago more than 1 year Were you ever a foster child? Yes No Are you a veteran? Yes No Do you have a disability? Yes No Condition If yes, are you receiving treatment? Physical Disability Yes No Yes No Developmental Disability Yes No Yes No Chronic Health Condition Yes No Yes No Mental Health Yes No Yes No Substance Abuse Yes No Yes No Please list any medications:

6 Please describe your current situation: DISCLOSURE STATEMENT Make sure that the application is filled out completely. If there are sections that don t apply to you, please write N/A for Not Applicable so that we know you didn t just leave it blank. If any part of the application is incomplete, it will not be reviewed for eligibility. Please understand that we will be asking for verification of homeless status, all household income, all disabilities, employment, credit history, criminal background and any other areas as necessary. By signing below, I agree that the information I have provided in this application is complete and true to the best of my knowledge. I understand that full disclosure of all of the information requested by staff members is a mandatory requirement of Homeless to Home and that if any information listed in this application packet is found to be untrue, my household will be immediately disqualified. Applicant Signature Date

7 Client Informed Consent & Authorization for Release of Information For Homeless Services Network HMIS This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions or desire any further information regarding this form, please contact the system administrator via the HSN HMIS Help Desk by phone ( x 120) or by (hmis@hsncfl.org). In order to best serve your needs at Harvest Time International, to develop meaningful treatment plans, to determine your continuing eligibility for services, and to monitor your progress in complying with the terms of your shelter, housing or other services, Harvest Time International and the Continuum of Care need to exchange, share, and/or release data, information or records they may collect about you. The information contained in your case records with any Agency is considered confidential and privileged and cannot be exchanged, shared and/or released without your express and informed written consent, except where otherwise authorized by law. Please understand that access to shelter, housing and services is available without your consent for the release of the information. However, your consent to share information with other service agencies is a critical component of our community s ability to provide the most effective services and housing possible. I understand that: This Agency may not refuse to serve me simply because I do not want my information shared with other service agencies. This form specifically authorizes the use of information about me in research conducted using information maintained characteristic in published research reports. The type of research that will be conducted using this information includes reports on the number and characteristics of people using different types of services, the effectiveness of services, and changes in patterns over time. If I give permission, the HSN HMIS will allow information about me, including records previously entered into the HSN HMIS, to be shared among HSN HMIS Partner agencies. This may include, but is not limited to, my photograph information regarding my education history and employment background, income, program eligibility and participation, and personal history. The purpose of sharing information is to help the agencies from which I seek services to obtain information about me faster, to assist with my case management, and to connect me more quickly with the services I need. Agencies that join the HSN HMIS after I sign this consent/authorization also will have access to the personal information that I authorize for data sharing. This Agency must make reasonable accommodations to allow me to view the updated list of HSN HMIS Partner Agencies. I understand that I have the right to inspect, copy and request all records maintained by an Agency relating to the provision of services provided by an Agency to me and to receive a copy of this form unless specifically denied under federal or state law. I understand that my records are protected by federal, state, and local regulation governing confidentiality of client records and cannot be disclosed without my written consent unless otherwise authorized by law. I understand that this release is valid for three years from the date I sign this document. I may revoke this authorization at any time verbally or by written request, but the cancellation will not be retroactive. I give my consent to the exchange of information via the HSN HMIS: Yes No I have read this document or it was read and/or explained to me and fully understand and agree with the terms of this document. Signature of client or guardian Date Signature of witness Date Printed name of client or guardian Printed name of witness