3. Needs assistance to communicate with the landlord or property manager Never Sometimes Often regarding the disability , accommodations needed (wheelchair Applicant’s ramp, bath grab bars, etc.), needed repairs, or other unit concerns Never Sometimes Often 4. Needs assistance to communicate with neighbors (For example, resolving disputes in a calm manner) 5. Needs assistance with household budgeting to ensure payment of rent Never Sometimes Often and avoid utility disconnection 6. Needs assistance keeping appointments and providing paperwork Never Sometimes Often necessary to maintain access to income/benefits. Does the applicant or member of the household have a substantial, long-term disability including but not limited to serious mental illness, Co-occurring disorder (mental illness and substance use disorder), developmental disability, physical or sensory disability, disability due to aging (i.e. or disability due to HIV/AIDS? “frail elder”) Yes No Does the applicant or member of the household need the Supportive Services provided by the PSH program to allow you to live in the community and not become evicted or homeless? Yes No Attestation: I attest that I have assessed this individual and/or their household member and I believe the person and/or household meets the criteria of being in need of permanent supportive housing services. Signature of Professional Completing Date
Never Sometimes Often 3. Needs assistance to communicate with the landlord or property manager regarding the Applicant’s disability , accommodations needed (wheelchair ramp, bath grab bars, etc.), needed repairs, or other unit concerns Never Sometimes Often 4. Needs assistance to communicate with neighbors (For example, resolving disputes in a calm manner) Never Sometimes Often 5. Needs assistance with household budgeting to ensure payment of rent and avoid utility disconnection Never Sometimes Often 6. Needs assistance keeping appointments and providing paperwork necessary to maintain access to income/benefits. Does the applicant or member of the household have a substantial, long-term disability including but not limited to serious mental illness, Co-occurring disorder (mental illness and substance use disorder), developmental disability, physical or sensory disability, disability due to aging (i.e. “frail elder”) or disability due to HIV/AIDS? Yes No Does the applicant or member of the household need the Supportive Services provided by the PSH program to allow you to live in the community and not become evicted or homeless? Yes No Attestation: I attest that I have assessed this individual and/or their household member and I believe the person and/or household meets the criteria of being in need of permanent supportive housing services. Signature of Professional Completing Date
Prosperity-Application-11-27-16.docx