CHESTER COUNTY DEPARTMENT OF MH/IDD

Mental Health Supportive Housing Options Application

01/07/2022

Name of applicant:

Telephone: ( ) - Email:

Current Living arrangements:

Gender: Male Female

Age: DOB: //
_____

Name of provider/referral source assisting with referral:

Please check to indicate application was completed with Applicant and referral source

Telephone/email (you may be called during the next Mental Health Housing Options Team (MHOT)
meeting if there are questions about the application)

Telephone: ( ) - Email:

The following application, and accompanying documentation, must be completed in its entirety in order to
be submitted and reviewed by MHOT. Utilize add attachments button for accompanying documentation,
and send completed form button to submit application.

Accompanying documentation Date completed:

Release of Information (on referring agency’s form) //

Physical examination (within 6 months of application, on physician’s form or form
included in this application). //

Psychiatric evaluation (within 1 year of application). //

Does applicant meet homelessness criteria (HUD definition)? Yes No
If yes, please specify:

Does applicant meet chronically homelessness criteria (HUD definition)? Yes No

If yes, please specify:

What Supportive Housing and/or Supportive Housing Services are being sought (see Services document for
descriptions)?

Why are above Supportive Housing and/or Supportive Housing Services being sought at this time?

How does the applicant feel Supportive Housing and/or Supportive Housing Services can assist them with
moving to more independent living?

How has applicant been preparing for more independent living?

What needs does applicant have that may pose a challenge to independent living?

Does applicant prefer to live Alone Roommate(s)

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MEDICAL INFORMATION:

Physician: Phone #: ( ) -

Psychiatrist: Phone #: ( ) -

Therapist: Phone #: ( ) -

Dentist: Phone #: ( ) -

Special medical concerns: Yes No

If yes, please explain condition(s) below or note on the physical form:

History of psychiatric hospitalizations:

Name of Hospital Admission Type Admission Date: Length of stay:

Known factors that precipitate psychiatric hospitalizations:

SOCIAL SERVICE AGENCY INVOLVEMENT:

Has applicant ever received Mental Health Supportive Housing and/or Supportive Housing Services in Chester
County or any other County? Yes No

If yes, please include name(s) and date(s)

Has applicant been involved with any other Mental Health service provider? Yes No
If yes, please include name(s), and date(s)

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LEGAL SYSTEM INVOLVEMENT:
Any past or present legal involvement? Yes No
If yes, County/State?
If yes, please describe:

Is applicant currently on Probation or Parole? Yes No

If yes, please list contact information
If yes, is applicant following the terms of probation/parole?

EDUCATION:

Please check the educational achievement(s) applicant has attained:

Less than a High School degree Associates Degree

High School Diploma Bachelor’s Degree
G.E.D. Graduate Degree
Some College, No Degree Specialized Training

BUDGETING:

Does applicant have a rep payee? Yes No

If yes, please list who:

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Monthly Income(net, after taxes): Monthly Expenses:

Employment (Full/ Part-time) Housing

Mortgage/Rent
Unemployment Insurance/Taxes
Electricity
Public Assistance / Food Stamps
Gas/Oil/Heat
Child Support/Alimony Water/Trash
Telephone/Cell Phone
Pensions
Internet/Cable
SSI / SSDI Food
Transportation
Other
Car Payments / Public Transportation
TOTAL $0.00 Gas
Auto Insurance
License/Tax/Tags
Maintenance incl. Oil changes
School/Child Care
Tuition/Books/Materials
Transportation/Lunches
Child Care/Babysitters
Debts (not car & house)
Student Loans
Personal Loans/ Leases
Credit Cards
Other
Entertainment/Recreation
Eating Out
Movies / Activities / Vacation
Pets
Medical Expenses
Insurance Premiums
Doctor co-pays/Prescriptions
Miscellaneous
Toiletries/Cosmetics
Beauty/Barber
Laundry/Cleaning
Allowances
Gifts (incl Christmas)
Clothing: adults and children
Life Insurance
Savings (Retirement & Other)
Storage
Fines
TOTAL $0.00

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ACTIVITIES:

What programs, activities, employment, and/or volunteer opportunities is the applicant currently involved in?

What programs, activities, employment, and/or volunteer opportunities will the applicant be involved in if
accepted into Mental Health Supportive Housing and/or Supportive Housing Services?

PERSONAL SUPPORT INFORMATION:

With the person’s consent, please list family members and/or significant others and indicate their involvement
in the person’s treatment:

Does applicant have children? Yes No

If yes, are they actively involved with their children? Yes No

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 CHESTER COUNTY DEPARTMENT OF MH/IDD
MEDICAL / PHYSICAL EXAMINATION FORM

Name:

Address:

Marital Status:
_________
Phone # ( ) - DOB // SS #:

Primary Care Physician:

Other Medical Specialists:

______________________
Emergency contact (Name, Address, Phone #, Relationship):

Name of Medical Insurance Carrier:

Allergies (Medications, dyes, shellfish, etc.):

Blood Pressure:
Temperature:
Last Tetanus Immunization:
List current Medical and Psychiatric Diagnoses:

List previous medical hospitalizations and/or surgeries:

Height: Weight: Eye color:

Hair Color: Race:

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MEDICAL/PHYSICAL EXAMINATION FORM continued:

Current Medications Prescribed By: Dosage: Frequency:

Medical History (check all that apply):

Rheumatic fever: Hay fever: Thyroid disease

Angina Asthma Stomach ulcers

Heart attack Lung disease. Gallbladder disease

Heart disease Emphysema Lyme disease

High blood Pressure Diabetes Hepatitis

Anemia Cancer Colitis

Kidney disease Arthritis Bladder Infection

Migraine Stroke Seizures

Gout
Social Habits:

Tobacco: Yes No Frequency

Alcohol: Yes No Frequency
Drugs: Yes No Frequency

Adaptive Equipment:

Does the person wear eye glasses/contacts? Yes No

Does the person wear dentures? Yes No

Does person require any other adaptive equipment? Yes No

Please list the any other adaptive equipment that is needed:

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MEDICAL/PHYSICAL EXAMINATION FORM continued:

Describe all Scars and Tattoos

Scars:

Tattoos:

Physical Examination Results:

General Physical Health: Good Fair Poor

Blood type:

Tuberculosis test required per CRR regulations: Date of PPD // Date of results: //
test:
Results: Positive Negative Results of x-ray if applicable:

Are there any known communicable disease(s)? Yes No

If yes please indicate:

Are there recommendations as a result of this physical?

If yes, please note:

Name, address and phone number of physician completing this form:

Physician’s signature: ______________________________________________ Date: ______________

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 CHESTER COUNTY DEPARTMENT OF MH/IDD
PSYCHOSOCIAL ASSESSMENT

Name of Applicant:

Name person completing the assessment:

Relationship to Applicant:

Date of Assessment: //

How long have you known the applicant?

Instructions:
Select the rating number that best reflects applicant’s current level of functioning, and enter the appropriate number
in each space provided. Base your answers on how persons of similar age, gender, culture, and general background
manage these activities in everyday living.

RATINGS FOR SECTIONS 1 THROUGH 8:

5 – Self-sufficient
4 – Needs verbal cues/assistance
3 – Needs training or supervision
2 – Needs substantial help/assistance
1 – Totally dependent
NA – Not applicable.

THERE IS NO “0”

1. SELF – CARE/PRESERVATION SKILLS:

Ability to attend to personal hygiene

Ability to practice good grooming
Ability to maintain clothing
Ability to exit residence independently in case of fire
Ability to walk in community safely
Ability to communicate needs

Yes No Does the person need an interpreter?

Yes No Does the person know and comprehend their rights?

Yes No Does the person request to live with people who are of the same gender?

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PSYCHOSOCIAL ASSESSMENT Continued:
2. HEALTH - CARE SKILLS:
Self – medication management
Knowledge and use of medical services
Knowledge and use of dental services
Ability to recognize symptoms of mental illness
Ability to recognize symptoms of bodily illness

3. HOUSEKEEPING SKILLS:
Ability to keep individual living space neat
Ability to keep bathroom clean
Ability to vacuum rugs when needed
Ability to sweep floors when needed
Ability to polish furniture when needed
Washes dishes when dirty
Knowledge of using a washer and dryer

4. ABILITY TO MEET NUTRITIONAL NEEDS:

Ability to develop and follow a weekly menu
Ability to prepare a list and purchase groceries
Ability to cook simple canned and frozen foods
Ability to use stove/oven
Ability to use a microwave oven
Ability to follow dietary restrictions/recommendations
Ability to follow a recipe

5. MOBILITY:
Ability to navigate stairs
Ability to move around safely in the community
Ability to use public transportation
Ability to safely operate motor vehicle
Yes No Is adaptive equipment needed for mobility purposes?

6. MONEY MANAGEMENT:
Understands income sources
Uses bank services
Pays bills on time
Safeguards money
Able to manage personal finances
Maintain a checking/savings account
Balances account

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PSYCHOSOCIAL ASSESSMENT Continued:
7. VOCATIONAL/EDUCATION PURSUITS:

Yes No Interest in pursuing educational goals

Yes No Marketable skills for employment consideration
Motivation toward working
Ability to stay on task
Sustains interest in employment
Maintains job if employed
8. ACADEMIC SKILLS:
Basic reading skills
Advanced reading skills
Basic writing skills
Advanced writing skills
Basic math skills
Advanced math skills
Ability to tell time
Ability to structure time
RATINGS FOR SECTIONS 9 THROUGH 11
5 – Almost always
4 – Frequently
3 – Occasionally
2 – Rarely
1 – Never
0 – Not applicable
9. USE OF LEISURE TIME:
Plans leisure activities/hobbies
Participates in activities/hobbies
Knows of and utilizes resources in the community

10. INTERPERSONAL/SOCIAL SKILLS:

Likes being with others in a group setting
Likes being with one or two others
Communicates needs and wishes appropriately
Tendency to manipulate others
Recognizes when being manipulated by others
Initiates friendships
Maintain friendships
Handle intimate relationships appropriately
Respects the privacy of others
Respects the property of others
Does not engage in offensive or unlawful sexual behaviors
Utilizes safe sex techniques
Adheres within the confines of the law
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 PSYCHOSOCIAL ASSESSMENT Continued:

11. SYMPTOM MANAGEMENT:

Able to handle constructive criticism
Historical or current symptoms of suicidal ideation
Historical or current symptoms of homicidal ideation
Historical or current symptoms of physically aggressive behavior
Historical or current symptoms of verbally abusive behavior
Historical or current symptoms of delusional tendencies
Historical or current symptoms of visual hallucinations
Historical or current symptoms of auditory hallucinations

Does the person utilize recovery tools to manage symptoms of their illness and their day-to-day life? Yes No
Has the person developed a WRAP or completed an Advanced Directive? Yes No
Additional Comments:

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 CHESTER COUNTY DEPARTMENT OF MH/IDD
DRUG & ALCOHOL SCREENING

Name of Applicant:
Name & phone # of Interviewer:
Date of Interview: //
Directions: Conduct a face-to-face interview. Check “Yes” or “No” for each question.
Yes No
1. Have you ever felt you used drugs and/or alcohol excessively?
2. Have you ever awakened the morning after drinking and/or drug use and found you could not
remember a part of the evening before?
3. Has your wife/ husband/ significant other/ children/ parents ever worried or complained about your
drinking and/or drug use?
4. Has your drinking or drug use ever made you feel unhappy?
5. Have you ever tried to limit your drinking and/or drug use to certain times of the day or to certain
places?
6. Have you been able to stop drinking and/or using drugs when you wanted to?

7. Have you ever attended and AA, NA or similar meeting(s)? If so, when & where?

8. Has your drinking and/or drug use ever created a problem with you or your family?

9. Have you gotten into fights when drinking and/or using drugs?

10. Has your wife/ husband/ significant other/ family member ever gone to anyone for help about your
drinking and/or drug use?
11. Have you ever spent time with people you don’t really care for just because of alcohol or other drugs?
12. Have you spent money on alcohol or drugs that was supposed to be spent on other things (e.g.
children’s clothing, rent, food, etc.)
13. Have you ever lost a job because of drinking and/or drug use? If so, when?
14. Have you had problems at work or school (lateness, missed time, errors, etc.) due to drinking and/or
drug use?
15. Have you ever consumed alcohol and/or used drugs at the beginning of your day?
16. Have you ever had a health problem as a result of drinking or drug use?
17. Have you ever had D.T.’s, severe shaking, heard voices, or seen things that weren’t there, after heavy
drinking and/or drug use?
18. Have you ever gone to anyone for help about your drinking and/or drug use?

19. Have you ever been hospitalized because of your drinking and/or drug use?
20. Were you ever arrested for an alcohol or drug related incident?
21. Have you ever used alcohol or drugs in order to feel more comfortable around people?
22. Have you ever taken a greater dosage of medication than was prescribed by your physician because
you felt like you just needed more to cope?
23. If you are accepted into Supportive Housing and/or Supportive Housing Services, are you willing to
have unannounced urine screens?
24. If you are accepted into Supportive Housing and/or Supportive Housing Services, are you willing to
attend AA/NA (Double Trouble) meetings as recommended by your doctor and/or treatment team?
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 Yes No

25. Are you currently receiving D & A treatment? If so, with whom?

26. Have you ever received D & A treatment in the past? If so, when and with whom?

27. If currently receiving D&A treatment, are you receiving drug screenings? Y/N If yes, results?

28. Have the interviewer and D&A provider communicated regarding recommendations and treatment?

How long have you been drug and/or alcohol free?

What is the longest length of time you have been drug and/or alcohol free?

Please expand on the “yes” answers to provide additional history and information:

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