City of Dallas Rapid Rehousing Application

City of Dallas Rapid Rehousing Program

Metro Dallas Homeless Alliance HMIS Privacy Notice
This Organization provides services for individuals and families at-risk of or experiencing homelessness. This Organization participates in the MDHA Homeless Management Information System (HMIS) and/or Coordinated Access System (CAS). The MDHA HMIS is used to collect basic information about clients receiving services from this Organization. This requirement was enacted to get a more accurate count of individuals and families experiencing homelessness, and to identify the need for different services. The MDHA CAS is used to connect individuals and families at-risk of or experiencing homelessness to the services they need. The HMIS is required by the US Department of Housing and Urban Development (HUD) for agencies that receive HUD funding. HMIS is not electronically connected to HUD and is only used to share information by local authorized agencies. This Organization only collects information that is considered appropriate and necessary. The collection and use of all personal information are guided by strict standards of privacy and security. This Organization may use or disclose information from the MDHA HMIS and/or the MDHA CAS under the following circumstances: • To provide or coordinate services for an individual or household; • For functions related to payment or reimbursement for services; • To carry out administrative functions; • When required by law; • For research and/or evaluation; • For creating de-identified data; or • To prevent or lessen a serious and imminent threat to the health or safety of an individual or the public in general A copy of the MDHA CoC Privacy Policy, describing allowable uses and disclosures of data collected for the purposes of the MDHA HMIS and/or the MDHA CAS, is available to all clients upon request. This privacy notice and the privacy policy may be amended at any time and those amendments may affect information obtained by the organization before the date of the change. Public Notice (Federal Register / Vol. 69, No. 146) / Effective August 30, 2004
Applicant Information
Name:*
First Last
Date:*
MM slash DD slash YYYY
Temporary Address:*
Street Address Address Line 2 City State ZIP Code
Highest grade completed:*
Contact Phone:*
Work Phone:
Email Address:
Social Security Number:*
Birthdate:*
MM slash DD slash YYYY
Age:*
Recent living situation:*
- Homeless from the streets
- Homeless from emergency shelter
- Transitional housing
- Psychiatric facility
- Substance abuse treatment facility
- Hospital or other medical facility
Ethnicity:*
- Hispanic
- Non-Hispanic
Race:*
- White
- Black
- Asian
- American Indian/Alaskan Native
- Native Hawaiian/Other Pacific Islander
- Black & White
- Asian & White
- American Indian & White
- American Indian & Black
- Other Multi-Racial
Marital Status:*
- Never married
- Separated
- Married
- Divorced
- Widowed
U.S. Citizen?*
- Yes
- No
Veteran?*
- Yes
- No
Pregnant?*
- Yes
- No
Due Date:
MM slash DD slash YYYY
Household Information
List all other persons who live with you (list Head of Household first). If any of the persons living with you is not a member of your family* and is simply a roommate or live-in attendant, please indicate this in the relationship blank. (Note that this designation cannot be changed in the future.)*
Last Name, First Name, MI Relationship to You DOB Sex Veteran? Race Highest Grade
Family means persons who are related to you, and includes persons living with you who are determined to be important to your care and well-being.*
Family Member Wages/Salaries Benefits/Pensions Public Assistance Other Income Asset Income
Do you have medical expenses not covered by insurance?*
- Yes
- No
Are your dependents in child care?*
- Yes
- No
Have you or anyone else in your household applied for SSI or Social Security benefits and been denied?*
- Yes
- No
Date of most recent application:
MM slash DD slash YYYY
Do you have a checking or savings account, stocks, bonds, etc?*
- Yes
- No
Amount:
Car License #:
Car Make/Model/Year:
Do you or any member of your household have limitations due to health, age, or other conditions? (If yes, please specify):*
Are you currently on probation or parole?*
- Yes
- No
Parole Officer Name:
First Last
Contact Number:
Do you or any member of your household require special housing accommodations? (i.e., downstairs, bus line, ramp, handrails, etc) If yes, please specify:*
Have you or any member of your family over the age of 15 been convicted of a crime?*
- Yes
- No
When?
Where?
Have you lived in federally subsidized housing before?*
- Yes
- No
Where?
Are you receiving assistance from any other Social Service Agency?*
- Yes
- No
If yes, please list below:
Agency Service Case Manager Phone Number
Please list any credit cards, time payment, or other debts you or other household members have.
Name Amount
Are you or any member 18 or older currently a student or attending a job-training program?*
- Yes
- No
Please specify:
Do you have any pets?*
- Yes
- No
Type and number of pets:
Acknowledgment of Receipt:*
I acknowledge I have received the information listed below.
I, the Applicant, acknowledge receipt of the following documents, which are provided to me in connection with my application for assistance: Client Rights and Responsibilities (includes grievance process) and Statement of Confidentiality/Authorization to Release Information
Applicant Certification:*
I, the applicant, certify and acknowledge that:
• The information, provided on this Application and Worksheets (which are part of this Application) and used to determine my eligibility and amount of assistance, is true and correct to the best of my knowledge and belief. This information is subject to verification, and falsification of this information may be grounds for termination from the program and result in prosecution under federal and state laws.
• I am responsible for notifying my Case Manager in writing immediately (within 15 days) if there is a change in my family’s income or household members during the year and for updating this information during annual re-certification.
• Neither I nor any family member is receiving assistance under any other part of this program or under any other public housing assistance program, including but not limited to, Section 8, HOME, or other publicly assisted housing.
• Assistance under this program may not be paid to me or to any family member, even if that family member is my landlord/mortgagee and does not reside with me.
• Assistance under this program is contingent on continued grant funding for the program.
E-Signature Acknowledgment*
I understand that typing my name below and throughout this contract serves as a legally binding digital signature.
E-Signature of Applicant/Head of Household:*
Date:*
MM slash DD slash YYYY
E-Signature of Spouse or Co-Tenant:
Date:
MM slash DD slash YYYY
Income Screening
Applicant Name:*
First Last
Date:*
MM slash DD slash YYYY
Assets:
Family Member Name Cash Value of Asset Annual Income Verification Document
Subtotal of Cash Value of Assets:
Subtotal of Annual Income for Assets:
Public Assistance:
Family Member Name Type of Assistance Annual Income Verification Document
Subtotal of Public Assistance:
Wages & Salaries:
Family Member Name Name of Employer Annual Income Verification Document
Subtotal of Wages & Salaries:
Benefits & Pensions:
Family Member Name Name of Employer Annual Income Verification Document
Subtotal of Benefits & Pensions:
Other Income:
Family Member Name Source of Income Annual Income Verification Document
Subtotal of Other Annual Income:
Grand Total:*
Assets Public Assistance Wages & Salaries Benefits & Pensions Other Income
Gross Grand Total:*
Monthly Gross Income (Gross Grand Total / 12):*
Certification of Accuracy*
By signing below, I, the Applicant, certify that the information and statements provided above are true and complete to the best of my knowledge and belief. This information is subject to verification, and falsification of this information may be grounds for termination from the program and result in prosecution under federal and state laws.
E-Signature of Applicant:*
Date:*
MM slash DD slash YYYY
E-Signature of Case Manager:*
Date:*
MM slash DD slash YYYY
City of Dallas Rapid Rehousing Program Declaration of Homelessness
Case No./Name:*
Date:
MM slash DD slash YYYY
Applicant Name:*
First Last
Applicant Email Address:
Applicant Social Security Number:*
Date of Birth:*
MM slash DD slash YYYY
Homelessness Declaration:*
I certify that: My household is “homeless”, as an individual or family who meets one of the categories below.
Select the category that best describes the applicant's current situation:*
- Category 1: Literally Homeless; residing in a place not meant for human habitation
- Category 2: Imminent Risk of Homelessness; will imminently lose primary nighttime residence
- Category 3: Homeless Under Other Federal Statutes
- Category 4: Fleeing/Attempting to Flee DV
For Category 1, the applicant is currently:
- Residing in a place not meant for human habitation (streets, cars, parks, sidewalks, abandoned buildings
- Residing in homeless shelters or treatment program
- Being discharged within a week from an institution or a jail/prison in which the person has been a resident for 90 days or less and no subsequent residence has been identified and lacks the resources and support networks needed to obtain housing
Further Instructions
Please download the City of Dallas Declaration of Homelessness document from Family Gateway's website to review the required documentation for each category or ask your caseworker.
Certification:*
I certify and acknowledge that the information provided here will be used to determine my eligibility and amount of assistance and that the information is true and correct to the best of my knowledge. This information is subject to verification, and falsification of this information may be grounds for termination from the program and result in prosecution under federal and state laws.
E-Signature of Applicant (please type your name in the box below):*
Date:*
MM slash DD slash YYYY
To be signed by Caseworker AFTER SUBMISSION
Signature of Caseworker:
Date:
MM slash DD slash YYYY
Statement of Confidentiality / Authorization to Release Information (Part 1)
Applicant Name:*
First Last
Current Address:*
Street Address Address Line 2 City State ZIP Code
Home Phone:*
Work Phone:
Statement of Confidentiality
It is the policy of the Program to treat your records as confidential and not disclose them, without your written authorization, subject to certain disclosures that are permitted or required by law. This means that confidential information will not be disclosed (even to family or household members) without your authorization. In an effort, though, to provide all the services for which you are eligible, it is necessary that we have your authorization to release information to other participating agencies/entities/persons involved in providing Program services to you. This information may be entered into a computer database that other social service agencies are able to access. Program services will be contingent on the Program’s ability to share information with these other agencies/entities/persons.
Authorization:*
I understand that confidential information may be shared with the agencies/ entities/persons checked below, and that such agencies/entities/persons may share confidential information with us, for the purpose of providing program services.
Landlord
Utility Company(ies)
City of Dallas Housing/Community Services
Dallas County Health & Human Services
Texas Dept. of State Health Services
U.S. Dept. of Housing & Urban Development
Dallas Housing Authority
Section 8 Housing
Texas Department of Criminal Justice
Metro Care/MHMR
NorthStar
Social Security Administration
Parkland/ HOMES Clinic
Veteran’s Administration
Human Services Network
North Dallas Shared Ministries
Emergency/Alternate Contact (listed below)
LifeNet Community Behavioral Health
ABC Behavioral Health
Legal Aid of North West Texas
Dallas County Health Department
HMIS
Metro Dallas Homeless Alliance
You may share my information with the other entities/family members listed below:
Emergency/Alternate Contact:
Emergency Contact Name:*
First Last
Emergency Contact Address:
Street Address Address Line 2 City State ZIP Code
Emergency Contact Home Phone:*
Emergency Contact Work Phone:
I authorize the program service provider to contact me (check all that apply):*
- By mail
- At my home phone
- On my answering machine
- At my work phone
- By leaving a message at my work
- I authorize the program service provider to identify itself by name
Other instructions, if needed:
Authorization*
By signing below, I, the Applicant, authorize the Program to share confidential information with the agencies/ entities/persons identified above. I acknowledge that I may withdraw this authorization at any time in writing. I further release the program from all legal responsibility and liability that may arise from the action I have authorized here.
E-Signature of Applicant:*
Date:*
MM slash DD slash YYYY
E-Signature of Case Worker:*
Date:*
MM slash DD slash YYYY
Statement of Confidentiality / Authorization to Release Information (Individual Agency)
Client Name:*
First Last
Current Address:
Street Address Address Line 2 City State ZIP Code
Date of birth:*
MM slash DD slash YYYY
Social Security Number:*
Referring Case Manager:*
First Last
Phone:*
Effective Date:*
MM slash DD slash YYYY
Expiration Date:*
MM slash DD slash YYYY
I hereby authorize The City of Dallas Rapid Rehousing Program to (check one):*
- Obtain from the following
- Release to the following
Name:*
Address:*
Street Address Address Line 2 City State ZIP Code
The following documents/information from the records pertaining to services received on Date of Service:
The documents to be released are described or listed as:
The records are required for the specific purpose of:
Authorization*
I understand that my authorization will remain effective from the date of my signature until the expiration date, and that the information will be handled confidentially in compliance with all applicable federal laws. I understand that I may see the information that is to be sent, and that I may revoke the authorization at any time by written, dated communication.
I have read and understand the nature of this release.
E-Signature of Client:*
Date:*
MM slash DD slash YYYY
E-Signature of Case Manager/Witness:*
Date:*
MM slash DD slash YYYY
Rights & Responsibilities
Name of Program Participant:*
First Last
As a Program Participant of City of Dallas you have a right to:
 Be treated with respect, dignity and professionalism, and in a caring manner that appreciates differences related to race, ethnicity, national origin, gender, sexual orientation, religion, personal values, age, disability, and economic or veteran status.  Confidentiality. This means that, without your written permission, no information about you is available to anyone outside of Family Gateway, including family members, friends, or outside agencies. However, there are certain exceptions, noted below, with which you should be aware - please read carefully through these exceptions, and be sure to ask your Case Manager if you have any questions: Exceptions to Confidentiality: • If appropriate, your Case Manger may consult with your treating physician or other healthcare providers to coordinate your care; • If you pose a threat of harm to yourself, to another person, or to the A Way Home community, we will take whatever steps are required by law, or permitted by law, to help prevent the potential harm from happening. This may include contacting your family and/or authorities; • In the event of a psychiatric hospitalization; • If you report information indicating that a child, disabled, or elderly person is suffering abuse or neglect; • A court order, issued by a judge, could require us to release information contained in your records, or could require a Family Gateway staff member to testify; • If you have been mandated by Family Gateway staff to seek an evaluation.  Discuss with your Case Manager what information is in your record, and if you sign a release of information authorizing Family Gateway to share information with outside sources, you have a right to discuss specifically what information will be released.  Request a different Case Manager if you become dissatisfied with your initial assignment. Reassignment will depend upon availability of alternate Case Management staff.  Be informed about the services available to you at Family Gateway.  Be provided with a safe environment to conduct your visits in.  Choose to use or not to use other Family Gateway services outside of A Way Home.  Receive accurate and relevant information in a timely manner.  File a grievance if you feel you have been mistreated and/or wronged and expect that the grievance will be investigated appropriately and in confidence.  File an appeal within 10 days of receiving a discharge notice from Family Gateway.
As a Program Participant of City of Dallas Program you have a responsibility to:
 Be respectful of others, including all Family Gateway staff, interns, volunteers, and other program participants.  Be respectful of all property belonging to Family Gateway and to the Owner of Project Site.  Participate in a fit state (not under the influence of drugs or alcohol) in those Family Gateway services you choose.  Participate in visits and other services to maximize your benefits (turn off/silence mobile phones).  Maintain confidentiality regarding information about other program participants in groups or programs conducted by Family Gateway and partnering agencies.  Provide accurate information about yourself, including changes in income, additional household members, and/or marital status, in order to receive quality services.  Keep all scheduled appointments with your Case Manager. If you need to cancel an appointment, please contact your Case Manager 24 hours before the appointment.  Keep apartment unit in a safe and sanitary manner and in compliance with housing habitability standards.  Abide by the terms and conditions set forth by the property owners in the apartment complex lease for the unit in which you reside.  Follow all rules and guidelines listed in your Program Participant Expectations (PPE).
Acknowledgment of Review*
I have read the above rights and responsibilities.
Program Participant E-Signature:*
Date:*
MM slash DD slash YYYY
Case Manager E-Signature:*
Date:*
MM slash DD slash YYYY

Last Name, First Name, MI	Relationship to You	DOB	Sex	Veteran?	Race	Highest Grade

Family Member	Wages/Salaries	Benefits/Pensions	Public Assistance	Other Income	Asset Income

Agency	Service	Case Manager	Phone Number

Name	Amount

City of Dallas Rapid Rehousing Program

Metro Dallas Homeless Alliance HMIS Privacy Notice

Applicant Information

Household Information

Income Screening

City of Dallas Rapid Rehousing Program Declaration of Homelessness

Further Instructions

To be signed by Caseworker AFTER SUBMISSION

Statement of Confidentiality / Authorization to Release Information (Part 1)

Statement of Confidentiality

Emergency/Alternate Contact:

Statement of Confidentiality / Authorization to Release Information (Individual Agency)

Rights & Responsibilities

As a Program Participant of City of Dallas you have a right to:

As a Program Participant of City of Dallas Program you have a responsibility to: