Transitional Shelter ApplicationCouple Adult #1 Last Name * First Name * Birthdate * MM DD YYYY Social Security Optional Ethnic Origin * Check all that apply. Asian White Black and/or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Hispanic or Latino(a) Non-Hispanic or Latino(a) Client refused Client doesn't know Sex * Male Female Trans Male Trans Female Gender Non-conforming Phone * Enter 000 000 0000 if not applicable. (###) ### #### Email * Enter N/A if not applicable. Please list where you stayed last night: Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Length of Stay What type of home are you currently residing in? * Renting Owning A friend's home A family member's home On the streets How many times have you lived on the streets or in a shelter in the past three (3) years? * Enter 0 (zero) if not applicable. How many months have you been living on the street on in an emergency shelter in the past three (3) years? * Enter 0 (zero) if not applicable. Are you currently in treatment? * Yes No If yes, when is your expected release date? MM DD YYYY Are you currently in jail/prison? * Yes No If yes, when is your release date? MM DD YYYY Highest level of education: * No schooling completed Nursery school to 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade, No diploma High School diploma GED Post-Secondary School Are you a Veteran? * Yes No As a child, were you in foster care? * Yes No Are you a domestic violence victim/survivor? * Yes No Are you currently fleeing? * Yes No How long ago? Are you disabled? * Yes No Check all that apply. * Chronic mental illness Developmental disability Physical disability Chronic health condition HIV/AIDS Alcohol dependency Drug dependency None Do you have health insurance? * Yes No If yes, what is the name of your insurance? Are you pregnant? * Yes No If yes, when is your due date? MM DD YYYY Are you employed? * Yes No If yes, who is your Employer? Did you receive income for any of the following? * Check all that apply. SSI SSDI TANF (ADC) Unemployment Child Support WIC SNAP (Food Stamps) Other None How much did you receive? $ Adult #2 Last Name * First Name * Birthdate * MM DD YYYY Social Security Optional Ethnic Origin * Check all that apply. Asian White Black and/or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Hispanic or Latino(a) Non-Hispanic or Latino(a) Client refused Client doesn't know Sex * Male Female Trans Male Trans Female Gender Non-conforming Phone * Enter 000 000 0000 if not applicable. (###) ### #### Email * Enter N/A if not applicable. Please list where you stayed last night: Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Length of Stay What type of home are you currently residing in? * Renting Owning A friend's home A family member's home On the streets How many times have you lived on the streets or in a shelter in the past three (3) years? * Enter 0 (zero) if not applicable. How many months have you been living on the street or in an emergency shelter in the past three (3) years? * Enter 0 (zero) if not applicable. Are you currently in treatment? * Yes No If yes, when is your expected release date? MM DD YYYY Are you currently in jail/prison? * Yes No If yes, when is your release date? MM DD YYYY Highest level of education: * No schooling completed Nursery school to 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade, No diploma High School diploma GED Post-Secondary School Are you a Veteran? * Yes No As a child, were you in foster care? * Yes No Are you a domestic violence victim/survivor * Yes No Are you currently fleeing? * Yes No How long ago? Are you disabled? * Yes No Check all that apply. * Chronic mental illness Developmental disability Physical disability Chronic health condition HIV/AIDS Alcohol dependency Drug dependency None Do you have health insurance? * Yes No If yes, what is the name of your insurance? Are you pregnant? * Yes No If yes, when is your due date? MM DD YYYY Are you employed * Yes No If yes, who is your Employer? Did you receive income for any of the following? * SSI SSDI TANF (ADC) Unemployment Child Support WIC SNAP (Food Stamps) Other None How much did you receive? $ Backgrounds (including Central Registry and Sex Offender Registry) are checked before entrance to the shelter and those with convictions which are aggravated, aggressive, or sexual in nature, may not be approved to be sheltered in our facility. I (we) have truthfully answered the questions in this application and give permission for this information to be verified. I furthermore understand that assistance is offered as it is available, and that Hope Harbor, Inc. reserves the right to refuse assistance. Date * MM DD YYYY Release of Information I (we), as an applicant for assistance from Hope Harbor, Inc., understand that information may need to be exchanged between Hope Harbor, law enforcement, other agencies and churches in order to further assist me and agree to such. IMPORTANT: HOPE HARBOR is required to clear with the Grand Island Police Dept., Adult Protective Services and Child Protective Services, and any police department of former residence locations, criminal history of any person seeking shelter or help from this office. Law enforcement agencies may review our records upon their request. By signing this release form, I (we) give my permission for Hope Harbor, Inc. to request information and share information with other agencies, law enforcement, and churches, which includes, but is not limited to the agencies listed below. The purpose of sharing of information is to determine by eligibility for services and to assist me by making other referrals appropriate to my situation. This RELEASE OF INFORMATION FORM is valid for 12 months, beginning with the date of execution and will expire one year from the date below. Date * MM DD YYYY The following listed agencies are the most frequent contacts by Hope Harbor, Inc., however the release is not limited to these agencies: Grand Island Police Department Mid-Plains Center Community Action of Nebraska Hall County Housing Authority Nebraska Department of Corrections St. Francis Hospital/Third City Clinic Grand Island Public Schools Region 3 Behavioral Services Mary Lanning Church V.A. Hospitals Doctor's Office/Physicians Central Nebraska Goodwill Industries Vocational Rehabilitation Independence Rising Department fo Health and Human Services Hall County Corrections Futures Family Services United Way Salvation Army Landlords Crisis Center Crossroads Mission Friendship House HH Therapists Drug Court Families Care Richard Young Hospital State Parole/Probation Applicant's Employer Date * MM DD YYYY NMIS Nebraska Management Information System Consumers Informed Consent & Release of Information Authorization I understand information about me and/or my dependents listed below is entered into a database system called ServicePoint. This system helps to better understand homelessness, to improve service delivery and to evaluate the effectiveness of services provided. Participation in data collection is a critical component of our community's ability to provide the most effective services and housing possible. The information that is collected is protected by limiting access to the database and limiting what information may be shared. Access to the data and sharing of the data is in compliance with the standards set by the federal, state, and local regulations governing confidentially of client records. Every person and agency that is authorized to read or enter information into the system has signed an agreement to maintain the security and confidentiality of the information. By signing this form I authorize the following: The information collected by this agency will be included in ServicePoint and only partner agencies, which have entered into an HMIS Agency Participation Agreement at which I have obtained or sought out services, may use my information to: Produce a client profile at intake that will be shared with collaborating agencies Produce aggregate level reports regarding use of services Track individual program-level outcomes Identify unfilled service needs and plan for enhancements Allocate resources among agencies engaged in services By signing this form, I authorize the following: I authorize the partner agencies and their representatives to share basic information regarding my family members listed below and/or me. I understand that this information is for the purpose of assessing my/our needs for housing, utility assistance, food, counseling, and/or other services. The following Personal Protected Information (PPI) is shared in HMIS for any service project. Name Date of Birth Social Security Number Gender Ethnicity and Race Client Location Veteran Status Photo (if applicable) These additional fields may be collected and shared for housing, utility assistance, and other service projects: Homeless History Family Composition Income/Non-cash Domestic Violence Disabling Condition Housing Information Health Insurance Status Residence prior to project entry I understand that: The partner agencies have signed agreements to treat my information in a professional and confidential manner. I have the right to view the client confidentiality policies used by the HMIS partner agencies. Staff members of the partner agencies who will see my information have signed agreements to maintain confidentiality regarding my information. The release of my information does not guarantee that I will receive assistance; my refusal to authorize the use of my information does not disqualify me from receiving assistance. My records are protected by federal, state, and local regulations governing confidentially of client records and cannot be disclosed without my written consent unless otherwise provided for in the regulations. This authorization will remain in effect until I revoke it in writing, and I may revoke authorization at any time, if I revoke my authorization, all information about me already in the database will remain. This release is valid for one year from the date of my signature below. I understand I may withdraw my consent at any time. Partner Agencies: A list of the partner agencies within the Nebraska Homeless Management Information System (NMIS) may be viewed prior to signing this form. Auditors or funders who have legal rights to review the work of this agency, including the U.S. Department of Housing and Urban Development and Nebraska Department of Health and Human Services Homeless Assistance Program may see my information in HMIS related to the services I received and funded by their Department(s). * Select on of the following levels of consent. I give authorization for me and my dependents listed above, Protected Personal and relevant information to be entered into the NMIS and shared between Partner Agencies. I do not consent to the inclusion of personal information in the NMIS about me and any dependents listed above. Date * MM DD YYYY By entering your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application. Signature * First Name Last Name IMPORTANT: Additional documentation will need to be signed in person. Thank you!Your application is under review and you can expect a call or e-mail within 24-72 hours.
