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Annual Gathering: 2012 Emergency Solutions To Rapidly Re-House Homeless Households
Annual Gathering: 2012 Emergency Solutions To Rapidly Re-House Homeless Households
PROGRAM
(Helping Others Until Self-Empowered)
H.O.U.S.E. PROGRAM
The H.O.U.S.E. Program is an emergency shelter
program that is contracted to provided a safe temporary
emergency shelter to families referred by the
Department of Housing and Community Development
(DHCD) under the Emergency Assistance (EA) Program
of the Commonwealth of Massachusetts.
H.O.U.S.E. PROGRAM
The EA Shelters are apartments that are located within the
communities of our service area. The apartments are leased
and maintained through Catholic Social Services.
Each apartment has 3 bedrooms,
and is leased for a family of 6. The
apartments are completely furnished
and have all the basic requirements
needed for a homeless family to arrive
at the shelter at a moments notice.
H.O.U.S.E. PROGRAM
Intake and Triage
SS Location: _________________________________
Head of Household:
Entry Date: _____________DTA Office: ________________DTA Case Worker_______________
First: ________________________Middle:___________________Last:____________________
DOB: __________________ SS# ____________________ Phone #_______________________
M / F/Transgender
Second Adult:
First: ________________________Middle:___________________Last:____________________
DOB: __________________________________SS# ___________________________________
M / F/Transgender
U.S. Citizen Y N
Green Card Y N
2nd Adult
Single __Married __Divorced __Widowed
Does HOH receive SNAP and Cash Benefits? Yes No Cash Amt $______ SNAP $______
Do all Family Members Have Insurance Benefits at this time? Yes No Ins Co:________________
*** Please list all family members who will require assistance with Insurance benefits.
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Pregnancy:
Is anyone in the household pregnant: Yes / No
Who: _________________________________________Due Date: ________________________
Emergency Contact: ____________________________ Relationship: ______________________
Address: _______________________ Phone #: ______________________ Release: Yes No
H.O.U.S.E. PROGRAM
Family Member:
EA Six months:
ays Date:
d of Household:
ividual:
mily Size:
lter Name:
Date Placed:
SSN (last 4 digits):
Contact Number:
Males:
Females:
Address:
Contact Number:
Contact Number:
CD Homeless Coordinator:
TAO:
Contact Number:
A Case Manager:
TAO:
Contact Number:
our Re-housing Plan outlines specific activities intended to bring you closer to economic
lity and sustainable housing. Your goals, strengths and resources will be the basis for
loping a strategy to overcome homelessness as you, shelter staff and DHCD staff develops the
ousing plan.
hile you are in shelter, you will be expected to:
take part in activities leading to increased economic stability for 30 hours a week, such as:
job search or job training, and addressing any barriers to obtaining employment;
attend shelter meetings and workshops as a requirement of your re-housing plan;
meet with and cooperate with re-housing placement staff;
save 30% of your net income; and
accept an offer of housing unless you have good cause.
ur case manager and/or re-housing case manager will help connect you with appropriate
munity resources, including child care, transportation, medical and other supportive services,
eded.
1
H.O.U.S.E. PROGRAM
H.O.U.S.E. PROGRAM
Secure Housing
1. Explore all housing options
2. Collect necessary documentation
3. Address barriers: CORI, credit
H.O.U.S.E. PROGRAM
Economic Stability
1. Create a budget and repayment plan.
2. Work with DTA to enroll in ESP
H.O.U.S.E. PROGRAM
Health & Safety
1. Attend required workshops
2. Access any services identified in the assessment process.
3. Schedule and keep all necessary medical appointments.
4. Weekly hours in all activities add up to 30 hours , unless
H.O.U.S.E. PROGRAM
Childrens Stability
Register children for school,
TEST YOUR KNOWLEDGE: How much income must a family have in order to
afford market rent and avoid paying more than the recommended 30% of
their income towards rent in the state of Massachusetts?
EXPLORE ALL
HOUSING OPTIONS
COLLECT NECESSARY
DOCUMENTATION
SECURE
HOUSING
STRATEGY TO
INCREASE INCOME
ADDRESS BARRIERS:
CORI ISSUES
CREDIT ISSUES
UTILITY ARREARS
SS Location: _________________________________
Head of Household:
Entry Date: _____________DTA Office: ________________DTA Case Worker_______________
First: ________________________Middle:___________________Last:____________________
DOB: __________________ SS# ____________________ Phone #_______________________
M / F/Transgender
Second Adult:
First: ________________________Middle:___________________Last:____________________
DOB: __________________________________SS# ___________________________________
M / F/Transgender
U.S. Citizen Y N
Green Card Y N
2nd Adult
Single __Married __Divorced __Widowed
Does HOH receive SNAP and Cash Benefits? Yes No Cash Amt $______ SNAP $______
Do all Family Members Have Insurance Benefits at this time? Yes No Ins Co:________________
*** Please list all family members who will require assistance with Insurance benefits.
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Pregnancy:
Is anyone in the household pregnant: Yes / No
Who: _________________________________________Due Date: ________________________
Emergency Contact: ____________________________ Relationship: ______________________
Address: _______________________ Phone #: ______________________ Release: Yes No
Last updated on 02/6/2012
Child/Children Names:
1. ______________ _______________ ________________
First
Middle
Middle
Middle
Middle
Middle
Middle
- -
- -
- -
- -
- -
Last
Last
- -
Last
Last
Last
Last
Ethnicity:
HOH:
Hispanic _______
Secondary Adult:
Hispanic _______
Children: ____________ Hispanic _______
Children: ____________ Hispanic _______
Children: ____________ Hispanic _______
Children: ____________ Hispanic _______
Children: ____________ Hispanic _______
Race:
HOH:
_____White _____Asian _____Asian/White_____Multi-Racial _____American Indian/Alaskan Native
_____ Hawaiian/Other Pacific Island _____American Indian/Alaskan & White _____Black/African American /White
_____American Indian/Black ______Black/African American
Second Adult:
_____White _____Asian _____Asian/White_____Multi-Racial _____American Indian/Alaskan Native
_____ Hawaiian/Other Pacific Island _____American Indian/Alaskan & White _____Black/African American /White
_____American Indian/Black______Black/African American
Children:
_____White _____Asian _____Asian/White_____Multi-Racial _____American Indian/Alaskan Native
_____ Hawaiian/Other Pacific Island _____American Indian/Alaskan & White _____Black/African American /White
_____American Indian/Black______Black/African American
_____Overcrowding
_____Over Housed
_____Physical Disability
_____Relocation
_____Substandard Housing
_____ Substance Abuse behaviors
_____Unable to pay utilities
_____Other:
Education:
HOH:
_____Less than 9th grade
_____ Unknown
_____ Some High School _____ HS or GED _____ Post High School
Second Adult:
____Less than 9th grade
____ Unknown
_____ Some High School _____ HS or GED _____ Post High School
Employment/Programs:
HOH:
Employed Yes / No
Employed by: __________________________ Job Title: ______________________________
Programs enrolled in
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Second Adult:
Last updated on 02/6/2012
3
Employed Yes / No
Employed by: __________________________Job Title: ______________________________
Programs enrolled in:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Income: For ALL Family Members
Was income received in from any source in the past 30 days?
Family Member
_____No Income
_____Alimony/Spousal Support
__________/_________
_____Child Support
__________/_________
_____Earned employment Income __________/_________
_____Job Pension
__________/_________
_____Private Disability Insurance __________/_________
_____Public/General Assistance __________/_________
_____Rental Assistance
__________/_________
_____Retirement from Soc. Sec. __________/_________
_____Social Security Retirement __________/_________
_____SSDI
__________/_________
_____SSI
__________/_________
_____TANF/TAFDC/EAEDC
__________/_________
_____Unemployment Insurance _________/_________
_____Veterans Pension/Disability __________/_________
_____Workers Compensation
__________/_________
_____Other________________
__________/_________
Yes / No
Income Amount
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
Were non-cash benefits received from any source in the past 30 days? Yes / No
Family Member
Amount (If applicable)
_____Food Stamps
__________/_________
_____Free Care
__________/_________
_____Healthy Start
__________/_________
_____Medicaid
__________/_________
_____Medicare
__________/_________
_____State Childrens Health Ins __________/_________
_____WIC
__________/_________
_____VA Medical Services
_________/_________
_____Private Disability Ins
__________/_________
_____TANF Child Care
__________/_________
_____TANF Transport Services __________/_________
_____TANF/Other Funded Services_________/_________
_____Pub Hsg/Sec 8/other rental assist__________/_________
_____Unemployment Insurance _________/_________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
__________/_________
__________/__________
__________/__________
__________/__________
4
Special Conditions:
Condition
Affected HH Member/Condition
____None
____Alcohol Abuse 1
____Drug Abuse 1
____Developmental Disability
____Chronic Health Condition
____Domestic Violence
2
____HIV/AIDS
____Physical Disability
____Mental Health Problems 3
____________/____________
____________/____________
____________/____________
____________/____________
____________/____________
____________/____________
____________/____________
____________/____________
____________/____________
Receiving treatment or
Services for condition
_____No
_____Yes
_____No
_____Yes
_____No
_____Yes
_____No
_____Yes
_____N0
_____Yes
_____No
_____Yes
_____No
_____Yes
_____No
_____Yes
_____N0
_____Yes
1= If alcohol or drug abuse, is the abuse expected to last a long time and impair the persons ability to live
independently?
_____No
_____Yes
2= If DV when did the last experience occur?
____Within the past three months
____Three to six months ago
____Six to twelve months
____More than one year
3= if mental illness, is it expected to last a long time and impair the persons ability to live independently?
_____No
_____Yes
Shelter:
Have you been in a Family Shelter before? Yes / No Where was it located? ____________________________
If yes when did you enter____________ and when did you exit ______________.
Veteran Status:
Is the HOH a Veteran? Yes / No
Language:
Whats your Primary Language? ___________________ Would you like to enroll in ESL classes? Y N
Head of Household:
Family Member:
_________
Date placed:
____________
Head of Household:
Individual:
Contact Number:
Family Size:
Males:
Females:
Home Address:
Unit:
Contact Number:
Shelter Program:
Contact Number:
TAO:
Contact Number:
Initiate primary contact with your landlord in person, by telephone, or letter and
follow up with your landlord at a minimum of every 3 months.
Obtain 6 and 12 month lease compliance verification letters from your landlord.
10/4/2012
Head of Household:
Family Member:
The following activities are part of your plan to maintain housing and move towards economic
and housing self-sufficiency. The assessment tool may be used to identify appropriate areas of
concentration. Your and your case manager will review your participation and completion of
these activities on a monthly basis.
Important: If a member of your family has a mental or physical disability that may prevent
you from doing an activity, we may be able to modify the activities in your plan to help you
participate successfully. Please request an ADA Accommodation.
Health Issue: Yes No if yes, please explain and verify_____________________________
Activities
Activity Status
Progress
1. Lease Compliance and Ongoing Housing Search:
Y N
Comments
___________________________________
___________________________________
___________________________________
Y N
_______________________
____________________________________
____________________________________
____________________________________
Y N
_______________________
___________________________________
___________________________________
___________________________________
Y N
______________________
____________________________________
____________________________________
____________________________________
10/4/2012
Head of Household:
Family Member:
Activity Status
Progress
Comments
Y N
_______________________
____________________________________
____________________________________
____________________________________
Y N
_______________________
___________________________________
____________________________________
____________________________________
Y N
_______________________
____________________________________
____________________________________
____________________________________
Y N
_______________________
____________________________________
____________________________________
____________________________________
Y N
______________________
___________________________________
___________________________________
___________________________________
Y N
______________________
___________________________________
___________________________________
___________________________________
3
10/4/2012
Head of Household:
Family Member:
Y N
______________________
___________________________________
___________________________________
___________________________________
Y N
______________________
___________________________________
___________________________________
___________________________________
Y N
______________________
___________________________________
___________________________________
___________________________________
Y N
______________________
___________________________________
___________________________________
___________________________________
________ _______________
Additional notes:
__________________________________________________________________________
10/4/2012
Head of Household:
Family Member:
I understand that the stabilization plan is a work in progress and that I am responsible for
completing the agreed upon activities and cooperating in the development of new activities.
I understand that consistently participating in and completing the stabilization plan activities
and remaining eligible for Emergency Assistance benefits pursuant to 106 C.M.R. ch. 309 are
requirements for continuing eligibility for temporary housing assistance.
I acknowledge that I have received a copy of the Flex Funds Case Review Policy and agree
that the Policy is incorporated into my Re-housing and Stabilization Plan and forms a part of
that Plan.
I agree to accept any modifications to my Re-housing and Stabilization Plan that are required
by DHS as part of any amendment to the DHS standard form Re-housing and Stabilization
Plan.
I understand that any extension of my Flex Funds subsidy at the end of my current Flex Funds
subsidy is subject to program and funding availability.
I understand that, if additional Flex Fund extensions are unavailable at the end of my current
Flex Funds subsidy, I will remain eligible for temporary emergency shelter benefits, provided
that I have been in substantial compliance with the stabilization plan and remain otherwise
eligible for Emergency Assistance.
I also understand that if I fail to cooperate with the stabilization plan, which is considered
housing assistance program services, and then lose the Flex Funds unit, I will be ineligible for
temporary emergency shelter benefits as specified in 106 CMR 309.040 (B) (7).
_____________________________________________
Adult Household Member Signature
________________
Date
_____________________________________________
Stabilization Case Manager
________________
Date
Amendments
_______________________________________________________
_______________________________________________________
_______________________________________________________
5
________________
Date
Initial _________
10/4/2012
Head of Household:
Family Member:
10/4/2012