PSH PBV Signature Form

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
Contact Information Sheet
Head of Household:*
First Last
Spouse/Other Adult Name:
First Last
Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
County:*
Number of children in home:*
Phone 1:*
Phone 2:
Email Address 1:*
Email Address 2:
Head of Household Employer:
Employer Phone #:
Spouse/Other Adult Employer:
Employer Phone #:
Emergency/Alternate Contact
Emergency Contact 1 Name:*
First Last
Emergency Contact 1 Phone:*
Emergency Contact 1 Relationship:*
Emergency Contact 2 Name:
First Last
Emergency Contact 2 Phone:
Emergency Contact 2 Relationship:
Emergency Contact 3 Name:
First Last
Emergency Contact 3 Phone:
Emergency Contact 3 Relationship:
Emergency Contact 4 Name:
First Last
Emergency Contact 4 Phone:
Emergency Contact 4 Relationship:
PSH PBV DHA Housing Program Information
Thank you for your interest in Family Gateway’s Permanent Supportive Housing - Program Based Voucher program (PSH PBV). The PSH PBV program is supported by a partnership with vouchers from the Dallas Housing Authority (DHA). This program requires that each family (at least one adult with full custody of at least one child under the age of 18) be certified as literally homeless through the Coordinated Access System, and has a member with a documented disability upon application. Final eligibility for the program is certified by the Dallas Housing Authority and is subject to their screening process. The PSH PBV program prescribes to a Housing First mindset. This means that our agency works with you and your family to help you obtain housing with the least number of barriers. Once you and your family are housed, program compliance, sobriety, treatment etc. will never be grounds for program termination by Family Gateway. Service participation is voluntary, individualized, person-centered and directed. PSH PBV connects families experiencing homelessness to permanent housing through a tailored package of assistance that includes the use of rental assistance via a DHA voucher and targeted supportive services via a Family Gateway Housing Stability Case Manager to help households obtain permanent housing based on you and your family’s specific strengths and barriers for at least one year or longer if needed. Once you and your family feel you are ready to maintain your self-sufficiency without the assistance of Family Gateway you may be eligible for a standard Section 8 voucher from DHA, subject to their eligibility process. You may then use this voucher to move on to other housing that accepts Section 8 vouchers. For PSH PBV families, your rent calculation is determined by DHA and is outlined in your Housing Assistance Plan (HAP) contract. It will be either 30% of your income or $50 if you have zero income. It is very important that you demonstrate you and your family’s ability to pay rent each month to the leasing office, directly. Any changes in your income will need to be reported to DHA immediately to have your rent re-calculated. It is very important that you work with your case manager often on your housing stability plan and budget, so that we can help you continue to maintain your housing stability. You will be recertified for assistance annually by DHA, unless there are significant changes in your family.
What You Can Expect from Family Gateway
- Assist family with developing a plan of action that will empower the family to become self-sufficient. - Assist in setting & accomplishing goals that are within reach. - Providing resources for the benefit of the family.
What Family Gateway Needs from You
- Commit to attend case management appointments & other appointments set in the community. - Commit to setting goals & accomplishing the goals. - Abide by my Property Community Living Policies & TAA Lease Agreement
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 1 (please type first & last name):*
E-Signature of Applicant 2 (please type first & last name) if applicable:
Date:*
MM slash DD slash YYYY
Acknowledgment of Welcome Packet
By signing below, I acknowledge that I have received, read & understand the information included in the Welcome & Orientation Packet.I agree to participate in the program through case management and perform responsibilities for successful involvement in the Family Gateway Program.
E-Signature of Applicant 1 (please type first & last name):*
E-Signature of Applicant 2 (please type first & last name) if applicable:
Date:*
MM slash DD slash YYYY
Date:*
MM slash DD slash YYYY
Acknowledgment of Orientation
By signing below, I acknowledge that I have attended orientation with Family Gateway staff.
E-Signature of Applicant 1 (please type first & last name):*
E-Signature of Applicant 2 (please type first & last name) if applicable:
Date:*
MM slash DD slash YYYY
Consent for Release of Information
I hereby authorize: Family Gateway, and any of its employees to obtain and/or discuss information regarding myself or my family with potential and/or past service providers. The disclosure of information authorized herein is made for the purpose of coordinating housing stability for the aforementioned family, and such disclosure shall be limited to the following specific types of information: social, mental, emotional and casework assessment. I acknowledge & understand that any information shared will only be shared with organizations that are working with Family Gateway for my benefit. I also understand that the information will be used as a means to assist me in creating a plan of action to begin work on my goals and objectives. Information may be shared for a period that does not expire, unless written request for expiration is given, regarding the welfare of the above-named client(s) and family. I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance of such information. I give Family Gateway staff permission to share relevant information with partner organizations, which I and Family Gateway deem necessary to assist me in developing a community support system for my family to become self-sufficient.
E-Signature of Applicant 1 (please type first & last name):*
E-Signature of Applicant 2 (please type first & last name) if applicable:
Date:*
MM slash DD slash YYYY
Release of Liability
For and in consideration for me and my family, I hereby release and discharge Family Gateway, its directors, officers, agents, employees, and volunteers from and all responsibility and liability for any injury, illness, or any claim of any sort whatsoever arising in connection with the care and maintenance of myself or my child(ren)or those that I am the Guardian over. In addition to this, Family Gateway has permission to transport me and /or any member of my family. Transportation assistance via Family Gateway staff is never a guarantee, and is at the sole discretion of the staff and their supervisor. I acknowledge and authorize Family Gateway staff/interns and agents/outside agencies transporting on behalf of Family Gateway to transport myself and any of the individuals below:
List names, ages, and dates of birth of all individuals here.*
Acknowledgment 1*
I understand that if myself or any of the individuals listed above do not adhere to the transportation policies & regulations put forth by Family Gateway staff, interns or agents/outside agencies transporting on behalf of Family Gateway that I may lose transportation privileges in the future.
Acknowledgment 2*
I, also acknowledge that transportation involves an element of risk, and I assume all risks and hazards incidental to such participation.
Acknowledgment 3*
I, do hereby release, absolve, indemnify, and agree to forever hold harmless Family Gateway, its insurers, employees, and representatives, and its insurers, employees, and representatives, from any and all financial responsibility for any injury, illness, or death as a direct or indirect result of the transportation that is provided.
E-Signature of Applicant 1 (please type first & last name):*
E-Signature of Applicant 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Educational Release of Information
I/we am/are the parent(s) and/ or legal guardian(s) for the child(ren) below. As the parent/guardian of the children listed below, I, do hereby give Family Gateway Center full authorization to verify the attendance of my child(ren) on a and discuss school related information such as immunizations, behavior, suspensions, homework assignments, etc., while we are Guests of any of Family Gateway’s programs.
Please list names, ages, grades, and school for all children.*
E-Signature of Applicant 1 (please type first & last name):*
E-Signature of Applicant 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Consent for the Taking and Use of Photographs, Tape Recordings, Television, Web/Internet Film and Motion Pictures
I/we understand that there will be several times during my stay at Family Gateway that there will be activities where photographs, video recordings, media, and/television may be present. I also understand that I am able to revoke this permission with respect to materials, photographs, pictures, programs or recordings which have not already been created by a notice in writing delivered to the Family Gateway of such revocation. Please make your selection below.
Consent to Photograph
I/we therefore GRANT Family Gateway permission to use any likeness, recordings of voices, or quotes for promotional material for Family Gateway, its web pages, social media accounts, newsletter, or magazine, newspaper articles, or other material written about Family Gateway of myself/ourselves and the children that I am the parent/guardian, which are listed below:
List names, ages, and dates of birth of all individuals consented to photograph below.
E-Signature of Guest 1 (please type first & last name):
E-Signature of Guest 2 (please type first & last name):
Date:
MM slash DD slash YYYY
OR Decline of Photography
I/we understand that there will be several times during my stay at Family Gateway there will be activities where photographs, video recordings, media, and/television may be present and DECLINE Family Gateway’s permission to use utilize any likeness of my camper’s, recordings of their voices, or quotes for promotional material for Family Gateway, its web pages, social media accounts, newsletter, or magazine, newspaper articles, or other material written about Family Gateway.
E-Signature of Guest 1 (please type first & last name):
E-Signature of Guest 2 (please type first & last name):
Date:
MM slash DD slash YYYY
Mandated Reporting of Suspected Child Abuse & Neglect
Under the Child Protective Services Act, mandated reporters are required to report any suspicion of abuse or neglect to the appropriate authorities. The employees of Family Gateway are considered mandated reporters, under this law. The employees of Family Gateway are not required to discuss their suspicions with parents prior to reporting the matter to the appropriate authorities, nor are they required to investigate the cause of any suspicious marks, behavior or condition prior to making a report. Under the Act, mandated reporters can be held criminally responsible if they fail to report suspected abuse or neglect. We take this responsibility very seriously and will make all warranted reports to the appropriate authorities. The Child Protective Services Act is designed to protect the welfare and best interest of all children. As mandated reporters, the staff of Family Gateway cannot be held liable for reports made to Child Protective Services which are determined to be unfounded, provided the report was made in “good faith.” Causes for reporting suspected child abuse or neglect include, but are not limited to: - Unusual bruising, marks, or cuts on the child’s body; - Severe verbal reprimands; - Improper clothing relating to size, cleanliness, season; - Transporting a child without appropriate child restraints (e.g. car seats, seat belts,etc.); - Dropping off or picking up a child while under the influence of illegal drugs or alcohol - Not providing appropriate meals including a drink for your child; - Leaving a child unattended for any amount of time; - Failure to attend to the special needs of a disabled child; - Sending a sick child to school over medicated to hide symptoms, which wouldtypically require the child to be kept at home until symptoms subside. - Children who exhibit behavior consistent with an abusive situation.
Acknowledgment of Receipt*
I understand that Family Gateway staff is mandatory reporters of suspected child abuse. I realize that while on Family Gateway I am NOT to physically discipline my child under any circumstances. I realize and understand the causes for reporting suspected child abuse or neglect.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Family Rights & Responsibilities, Involuntary/Voluntary Program Exits, & Grievance Policies
I have downloaded and reviewed the full PDF packet, including the Family Rights & Responsibilities, Involuntary/Voluntary Program Exits, and Grievance Policies on pages 9-14.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Statement of Commitment
Family Gateway PSH Case Manager commits to do the following: - Assist family with developing a plan of action that will empower the family to become self-sufficient. - Assist in setting & accomplishing goals that are within reach. - Providing resources for the benefit of the family. - Provide case management, guidance & support to the family throughout their duration in the program. - Advocate to help client maintain/gain permanent stable housing. As a participant in the program, I will commit to the following: - Provide all documentation and information needed to create a personal plan of action. - Commit to attend appointments & other appointments set in the community. - Commit to attend all Annual Renewal Appointments with Property & Program to remain in good standing - Commit to setting goals & accomplishing the goals. - Commit to taking out time to meet and work with the case manager to work toward self-sufficiency. - Ensure that I will contact the case manager when I encounter any problems that would hinder my participation in the program. - Abide by my Property Community Living Policies & TAA Lease Agreement. By providing your signature, you are agreeing to fulfill your responsibilities above, as well as acknowledge the receipt of Family Gateway's participant policies.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Permanent Supportive Housing Agreement: Apartment Furniture, Fixtures, & Furnishings
Prelude: Resident(s) accepts the apartment, fixtures, and furniture as is, except for conditions materially affecting health or safety of ordinary persons. Resident(s) will not remove Owners fixtures or furniture from the apartment for any purpose. All furniture and furnishings provided to you when you move into your apartment is provided by Family Gateway, Inc. Family Gateway is not held responsible if your furniture is broken, torn or destroyed. Nor will Family Gateway replace your furniture if it is broken, torn or destroyed. By signing below, I acknowledge that I have received a copy of this and agree to abide by the conditions, as stated above, and acknowledge that ownership of furniture provided by Family Gateway is automatically transferred to Head of Household upon accepting of furnishings.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Disclosure of Lead Based Paint Hazards
LEAD WARNING STATEMENT: Housing built before 1978 may contain lead-based paint. Lead from paint, paint chips, and dust can pose heath hazards if not managed properly. Lead exposure is especially harmful to young children and pregnant women. Before renting pre-1978 housing, Family Gateway must disclose the presence of knownlead-based paint and/or lead-based paint hazards in the dwelling. Participants must also receive a federally approved pamphlet on lead poisoning prevention.
Family Gateway's Disclosure: Presence of lead-based paint and/or lead-based paint hazards (check (A) or (B) below).*
- Known lead-based paint and/or lead-based paint hazards are present in the housing.
- Family Gateway has no knowledge of lead-based paint or lead-based paint hazards in the housing.
Explanation, if needed:
Records and reports available to Family Gateway (check (A) or (B) below):*
- Family Gateway has provided the Participant with all available records and reports pertaining to lead-based paint and/or lead-based paint hazards in the housing (list in box below).
- Family Gateway has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.
Explanation, if needed:
Participant Acknowledgment 1*
Participant has received copies of all information listed above.
Participant Acknowledgment 2*
Participant has received the pamphlet Protect Your Family from Lead in Your Home .https://www.epa.gov/lead/protect-your-family-lead-your-home-real-estate-disclosure
Participant Acknowledgment 2*
Participant has received the pamphlet Protect Your Family from Lead in Your Home .https://www.epa.gov/lead/protect-your-family-lead-your-home-real-estate-disclosure
Staff Acknowledgment*
Staff had informed the Family Gateway of the obligations under 42 U.S.C. 4852d and is aware of his/her responsibility to ensure compliance.
Certification of Accuracy*
The following parties have reviewed the information above and certify, to the best of their knowledge, that the information they have provided is true and accurate.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
E-Signature of Staff Representative (please type first & last name):*
Notice of Occupancy Rights Under the Violence Against Women Act
Please download the full PDF packet and review the Notice of Occupancy Rights Under the Violence Against Women Act on pages 18-29.
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Enrollment Services & Assessment
Part 1: Basic Information
Applicant 1 Name:*
First Last
Applicant 2 Name:
First Last
Best Phone:*
Alternate Phone:
Part 2: Homelessness
Zip Code of last permanent housing:*
Where did you and your family stay last night? Choose one only.*
- Place not meant for habitation (car, tent, outside)
- Emergency shelter (including motel paid for by program/agency)
- Transitional shelter
- Safe haven
- Hospital (non-psychiatric), and was homeless prior to admission
- Psychiatric hospital, and was homeless prior to admission
- Substance abuse inpatient, and was homeless prior to admission
- Jail, prison, or juvenile detention, and was homeless prior to incarceration
- Fleeing domestic violence
- Permanent housing (City Gate, Lake Whatcom Tx Center) and facing eviction
- Rental by client without subsidy and facing eviction
- Rental by client with VASH subsidy and facing eviction
- Rental by client with other non-VASH subsidy and facing eviction
- Staying with family and facing eviction
- Staying with friends and facing eviction
- Owned by client w/out subsidy and facing foreclosure or has been condemned
- Owned by client with subsidy and facing foreclosure or has been condemned
- Hospital (non-psychiatric), and no place to go
- Psychiatric hospital, and no place to go
- Substance abuse inpatient, and no place to go
- Jail, prison, or juvenile detention, and no place to go
- Exiting foster care home or foster care group home, and no place to go
- Staying with family, unstable situation
- Staying with friends, unstable situation
- Hotel/motel paid for by client
How long have you and your family been staying at the type of place where you stayed last night?*
- 1 week or less
- Over 1 week, less than 1 month
- 1 to 3 months
- Over 3 months, less than 1 year
- 1 year or longer
Have you been continually homeless for a year or more?*
- Yes
- No
How many times have you been homeless in the past 3 years?*
- 0-3 times
- 4+ times
Additional notes about where you stayed in the last month, year, etc.
Reasons for homelessness or risk of homelessness (select all that apply).*
- Alcoholism
- Displacement
- Health problems
- Illness
- Mental health issues
- Substance abuse
- Domestic Violence
- Eviction
- Primarily economic reasons
- Criminal record
- Out of home youth
- Family crisis
- Don't know
- Other
If "Other", please describe below.
Part 3: Household Resources
Please record your household’s income from the last thirty days in the box below. List household member, income source, and income amount.*
Include any income from these sources: Earned income, unemployment insurance, Supplemental Security Income (SSI), Social Security Disability Income (SSDI), Veteran's disability payment, private disability insurance, worker's compensation, TANF, general assistance, Social Security retirement income, Veteran's pension, pension from a former job, child support, alimony or other spousal support, etc.
Total Household Monthly Income:*
Are any of the adults in the household employed?*
- Yes
- No
If yes, list household member, workplace, # of hours worked, and if the job is permanent, temporary, or seasonal.
Is anyone in the household looking to gain employment or increase work hours?*
- Yes
- No
If yes, list household member here:
Please identify which non-cash benefits the household has received in the last thirty days. Check all that apply.*
- Food stamps
- MEDICAID - Medical Assistance
- Medicare
- TX health care for children
- Veterans Admin (VA) medical services
- Private health insurance
- Earned Income Tax Credit
- TANF child care services
- TANF transportation services
- WIC
- Other TANF-funded services
- Section 8, public housing, or rental assistance
Have you received services or are you currently working with any other service providers? (check all that apply)*
- DHA or other PHA (Housing Authority)
- CPS
- Work Force
- Veterans Administration
- Other
If "Other", please describe.
Part 4: Household Needs
For the questions below, please list household members, the condition, and any services or treatment for each category.
Does anyone in the household have a developmental disability (i.e. ADD/ADHA, dyslexia, autism)?
Does anyone in the household have a mental health problem (i.e. anxiety, depression, schizophrenia, PTSD)?
Does anyone in the household have a CURRENT alcohol abuse problem?
Does anyone in the household have a CURRENT drug abuse problem?
Does anyone in the household have a physical disability (i.e. visual/hearing impairment, head injury, mobility impairment)?
Does anyone in the household have a chronic health condition (i.e. heart disease, severe asthma, diabetes, arthritis, cancer, epilepsy)?
Are you currently employed?*
- Yes
- No
If yes, where and how long have you been working in your position?
If no, do you feel you are ready to go to work at this time?
- Yes
- No
If no, why not?
If you are looking for a job, what type do you want?
- Temporary
- Permanent
- Seasonal
- Full-time
- Part-time
- Volunteer
- Anything
What barriers do you have in finding or maintaining a job? Select all that apply.*
- Child care
- Training
- Transportation
- Housing
- Getting along with others
- Interview skills
- Substance use/abuse
- Education
- Felony
- Legal status
- Language
- Lack of work experience
- Poor work history
- Physical health issues
- Mental health issues
- None
- Other
If "Other", please describe.
Have you received any assistance with your barriers?*
- Yes
- No
If yes, what?
Are you currently in school or in a training program?*
- Yes
- No
If yes, where and in what field?
Are you interested in pursuing an education or training program?*
- Yes
- No
If yes, in what?
Do you have any other training or skills?*
- Yes
- No
If yes, specify below.
Are you working with any other agencies on employment or educational goals? If so, who?
Anything else you would like to include regarding employment or educational goals?
Would you be interested in participating in the following services? Check all that apply.*
- Mainstream Benefit Assistance
- Budgeting Class
- Financial Assistance
- Children's Education
- Domestic Violence Education
- Employment Assistance
- GED Options
- Life Skills
- Medical/Dental Assistance
- Parenting Class
- Tutoring
- After School Care
- Child Care
- Recreational Activities
- Transportation Assistance
- Mental Health Services
- Legal Services
- Educational Services
- Family Counseling
- Meals
- Laundry
- Credit Repair Services
- Clothing
- Basic Necessities
- Furniture
- Substance Abuse Services
- Other
If other services, describe below.
Have you ever rented or owned an apt/house?*
- Yes
- No
Have you ever received a pay-or-vacate notice?*
- Yes
- No
Have you ever received an eviction notice?*
- Yes
- No
Do you owe money to a previous landlord?*
- Yes
- No
If yes, how much?
Are you making payments?
- Yes
- No
Have you ever been in a subsidized housing program through any Housing Authority? (Public Housing, Sec 8, S+C, Project-Based, etc)*
- Yes
- No
If yes, when and where?
Have you ever been evicted by any Housing Authority?*
- Yes
- No
Do you owe any money to any Housing Authority?*
- Yes
- No
If yes, how much?
Have you filed appeals?*
- Yes
- No
Are you making payments?*
- Yes
- No
Housing Assessment Tool
How many people do you anticipate living in your household?*
What is the minimum unit size acceptable for your family?*
Has your child received Child Protective Services in the last 12 months?*
- Yes
- No
Reunification (through state) pending?*
- Yes
- No
If yes, what is the due date?
Could you get a positive landlord reference?*
- Yes
- No
How many times have you been evicted/foreclosed on a house or you were asked to leave your housing?*
Do you have any debt to any utility companies?*
- Yes
- No
If yes, estimate how much you owe to utilities:
What is the estimated level of debt for your household (such as credit cards, hospital, car debt, and others)?*
Is your family interested in being referred to programs that specialize in serving persons with chemical dependency?*
- Yes
- No
Is your family interested in being referred to programs that specialize in serving persons with mental health/behavioral health needs?*
- Yes
- No
Is your family interested in being referred to programs that specialize in serving immigrants and refugees?*
- Yes
- No
Is your family interested in being referred to programs that specialize in serving persons from a specific cultural background?*
- Yes
- No
If yes, please indicate below.
Is your family interested in being referred to programs that specialize in serving survivors of domestic violence?*
- Yes
- No
Is your family interested in being referred to programs that specialize in employment and education services?*
- Yes
- No
Is your family interested in being referred to a program that requires someone in your household to have a disability?*
- Yes
- No
Does your family have any special accommodation needs (i.e. first floor apt, ramps, elevators, other)?*
- Yes
- No
If yes, please describe below.
Do you have a geographic presence? If yes, describe below.
If the housing option is not in this area, are you interested in other locations? Please describe below.
Do you require confidential housing due to safety concerns?*
- Yes
- No
In the case of domestic violence or other situations, which area(s) are unsafe?
Do you have a family pet?*
- Yes
- No
Is there anything else you would like us to know regarding your housing needs?
E-Signature of Guest 1 (please type first & last name):*
E-Signature of Guest 2 (please type first & last name):
Date:*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

Metro Dallas Homeless Alliance HMIS Privacy Notice

Contact Information Sheet

Emergency/Alternate Contact

PSH PBV DHA Housing Program Information

What You Can Expect from Family Gateway

What Family Gateway Needs from You

Acknowledgment of Welcome Packet

Acknowledgment of Orientation

Consent for Release of Information

Release of Liability

Educational Release of Information

Consent for the Taking and Use of Photographs, Tape Recordings, Television, Web/Internet Film and Motion Pictures

Mandated Reporting of Suspected Child Abuse & Neglect

Family Rights & Responsibilities, Involuntary/Voluntary Program Exits, & Grievance Policies

Statement of Commitment

Permanent Supportive Housing Agreement: Apartment Furniture, Fixtures, & Furnishings

Disclosure of Lead Based Paint Hazards

Notice of Occupancy Rights Under the Violence Against Women Act

Enrollment Services & Assessment

Part 1: Basic Information

Part 2: Homelessness

Part 3: Household Resources

Part 4: Household Needs

Housing Assessment Tool