Homeless Crisis Response Program Housing Status Documentation Form Applicant Name: _ ____ HMIS ID Number: ________________________________________________________ Staff Member Name: Household without dependent children (complete one form for each adult in the household) Household with dependent children (complete one form for household) Number of persons in the household: _________ This is to certify that the above-named individual or household is currently homeless based on the check mark, other indicated information, and signature indicating their current living situation. Check the appropriate type of documentation used to verify homelessness and attach it to this worksheet. Complete with information on the primary cause of homelessness. Check and complete only one living situation option. Documentation Living Situation Type of Eligible Documentation Attached Persons living on the street or Signed and dated written sleeping in a place not Yes No NA certification by person seeking designed for or ordinarily used services as a regular sleeping Signed and dated written accommodation. certification by an outreach worker Persons living in a shelter HMIS shelter/transitional housing designed to provide temporary Yes No NA record living arrangements Written referral from previous - congregate shelters shelter/transitional housing staff - transitional housing Written referral from charitable - hotels/motels paid for by a organization or government charitable organization or program government program. Persons exiting an institution HMIS shelter/transitional housing where they resided for 90 days Yes No NA record or less and was residing in a Written referral from previous place not meant for human emergency shelter stay habitation immediately before Written referral from institution entering institution. Persons fleeing domestic Written, signed and dated violence. Yes No NA verification from the participant Written, signed and dated verification from the domestic violence service provider
Homeless Crisis Response Program Housing Status Documentation Form Applicant Name: _ ____ HMIS ID Number: ________________________________________________________ Staff Member Name: Household without dependent children (complete one form for each adult in the household) Household with dependent children (complete one form for household) Number of persons in the household: _________ This is to certify that the above-named individual or household is currently homeless based on the check mark, other indicated information, and signature indicating their current living situation. Check the appropriate type of documentation used to verify homelessness and attach it to this worksheet. Complete with information on the primary cause of homelessness. Check and complete only one living situation option. Living Situation Type of Eligible Documentation Documentation Attached Persons living on the street or sleeping in a place not designed for or ordinarily used as a regular sleeping accommodation. Signed and dated written certification by person seeking services Signed and dated written certification by an outreach worker Yes No NA Persons living in a shelter designed to provide temporary living arrangements - congregate shelters - transitional housing - hotels/motels paid for by a charitable organization or government program. HMIS shelter/transitional housing record Written referral from previous shelter/transitional housing staff Written referral from charitable organization or government program Yes No NA Persons exiting an institution where they resided for 90 days or less and was residing in a place not meant for human habitation immediately before entering institution. HMIS shelter/transitional housing record Written referral from previous emergency shelter stay Written referral from institution Yes No NA Persons fleeing domestic violence. Written, signed and dated verification from the participant Written, signed and dated verification from the domestic violence service provider Yes No NA
TAB-1-ASSESSMENT-Revised-March-2017.docx