Supportive Housing Verification of Disability Form LinkedInThis field is for validation purposes and should be left unchanged.InstructionsA qualified professional with one of the following credentials (MD, DO, LCPC, LCSW, APRN-BC, NP) must complete this form. Sections 1 AND 2 of the form which apply to:Applicant Name:* First Last Applicant Date of Birth:* MM slash DD slash YYYY SECTION 1: APPLIES TO INDIVIDUALS WITH PSYCHIATRIC DISABILITIES, CHRONIC SUBSTANCE ABUSE AND HIV/AIDSThe above named individual is an adult having a physical, mental, or emotional impairment that: (a) is expected to be of long-continued and indefinite duration, AND (b) substantially impedes the person’s ability to live independently, AND (c) is such that the person’s ability to live independently could be improved by more suitable housing conditionsIf a, b, and c above are true then please select ‘Yes’, otherwise select ‘No’* Yes No SECTION 2: APPLIES TO ALL INDIVIDUALSFor each numbered item below, mark an “X” in the applicable box that accurately describes the person listed above.Applicant has a physical, mental, or emotional impairment that is expected to be of long- continued and indefinite duration, substantially impedes his or her ability to live independently, and is of a nature that such ability could be improved by more suitable housing conditions.* Yes No The applicant is a person with a developmental disability, as defined in Section 102(7) of the Developmental Disabilities Assistance and Bill of Rights Act (42 U.S.C. 6001(8)), i.e., a person with a severe chronic disability that: a. Is attributable to a mental or physical impairment or combination of mental and physical impairments; b. Is manifested before the person attains age 22; c. Is likely to continue indefinitely; d. Results in substantial functional limitation in three or more of the followingareas of major life activity; (1) Self-care, (2) Receptive and expressive language, (3) Learning, (4) Mobility, (5) Self-direction, (6) Capacity for independent living, and (7) Economic self-sufficiency; and e. Reflects the person's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated.* Yes No The applicant is a person with a chronic mental illness, i.e., he or she has a severe and persistent mental or emotional impairment that seriously limits his or her ability to live independently, and whose impairment could be improved by more suitable housing conditions.* Yes No The applicant is a person whose sole impairment is alcoholism or drug addiction.* Yes No Name & Title of Person Supplying the Information:*Firm/Organization Name:*E-Signature (please type your name in the box below):*Date:* MM slash DD slash YYYY Release* I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are circumstances that would require the owner to verify information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of this consent.E-Signature (please type your name in the box below):*Date:* MM slash DD slash YYYY
