Housing Services Application

Date:(Required)

Month

Day

Year

Applicant Name:(Required)

First Last

Date of Birth:(Required)

Month

Day

Year

Referral Source:(Required)

Referral Contact Information:(Required)

Referral Email:(Required)

Applicant's Contact Information:(Required)

Applicant's County of Financial Responsibility:(Required)

Applicant's MA/Insurance #:(Required)

Applicant's Employment Status:(Required)

Applicant's Monthly Income/Type:(Required)

Applicant's Gender Identification:(Required)

Applicant's Preferred Pronouns:(Required)

What type of housing is applicant moving from?(Required)

What type of housing is applicant interested in?(Required)

Hiawatha Bluffs Living (HBL)

Board and Lodge

Scattered Site

Is the applicant on a civil commitment?(Required)

Yes

If yes, what is the commitment term?

File Upload

Max. file size: 50 MB.

Please indicate if the applicant is receiving any of the below services and also indicate provider’s name and agency when applicable:

Guardian:

Conservator:

Representative Payee:

Case Manager:

ARMHS Practitioner:

Psychiatric Provider:

Therapist/Counselor:

Chemical Dependency Services:

Pharmacy:

Primary Care Provider:

Employment Services:

PCA/Waivered Services:

Probation/Parole Officer:

Other involved services/agencies:

Applicant's Mental Health Diagnosis:(Required)

Please upload current DA’s or Comp Evals

Max. file size: 50 MB.

Is the applicant medication compliant?(Required)

Which medications does applicant currently take? (List or upload med list)(Required)

Upload Medication List

Max. file size: 50 MB.

Which services will need to be changed due to a move to a HVMHC Housing Program?(Required)

Please explain how his/her/their illness affects daily functioning:(Required)

Chemical Health/SUD Diagnosis:(Required)

When was the last time, to your knowledge, that the applicant has used illegal substances (I.E. drugs) or legal substances (I.E. alcohol or cannabis)?(Required)

How does his/her/their Substance use affect their functioning?

Is the applicant physically disabled or hearing impaired?(Required)

Will the applicant require a handicap accessible unit/room?(Required)

Does this person require any special assistance/equipment/accommodations? If so, please explain:(Required)

*Please note that the board and lodge programs are not handicap accessible.

Has the client:

Attempted suicide? If so, please explain:

Engaged in self-injurious behaviors? If so, please explain:

Frequently eaten too little or too much? If so, please explain:

Physically assaulted someone? If so, please explain:

Threatened to harm others? If so, please explain:

Does the client have the following emotional symptoms or experiences?

Stress/anxiety. If so, please explain:

Angry outbursts or extreme mood swings. If so, please explain:

Manic symptoms. If so, please explain:

Passive to abusive situations. If so, please explain:

Vulnerable to naiveté. If so, please explain:

Significant trauma in his/her life. If so, please explain:

History of sexual trauma. If so, please explain:

History of predatory sexual behavior. If so, please explain:

History of sexually inappropriate behavior. If so, please explain:

History of inability to manage funds. If so, please explain:

Risk of being taken advantage of financially. If so, please explain:

May take advantage of others financially. If so, please explain:

Current legal issues, or pending charges. If so, please provide specific details:

Past legal issues. If so, please provide specific details:

Medical health issues. If so, please provide specific details, including pending treatments/surgeries:

Limitations to mobility, sight, hearing, etc.:

HVMHC's residential programs are available to assist individuals with serious mental illness, with or without history of chemical dependency, who exhibit unsuccessful community living stability, and who have had varying types of housing and legal history. As the referring agent, please help us understand the applicant’s history by answering the questions below:

1.) Please check those that apply below:(Required)

In the last 3 years, the applicant has been committed as MI (person with mental illness) or MI/CD (a person with mental illness and chemical dependency) twice or had a commitment extended.

In the last 3 years, the applicant has been treated in an IRTS (Intense Residential Treatment Service) facility twice.

Due to mental illness symptoms or behaviors, the applicant has had repeated involvement with law enforcement during the last 3 years.

The applicant has been admitted to an inpatient psychiatric unit at least twice in the last 3 years.

N/A

2.) Please indicate if the applicant has/had a charge of:(Required)

Arson

Methamphetamine production

Level III Sexual Offense (Designated)

N/A

3.) Please indicate the applicant’s homelessness status:(Required)

Long-term homelessness: The applicant is lacking a permanent place to live continuously for a year or more or at least four times in the past.

At risk of long term homelessness: The applicant is at risk of long-term homelessness due to being faced with a set of circumstances that is likely to cause the household to become homeless in the future, including: living in substandard housing, living in housing that is inadequate for the size of the household, living in housing with a person who engages in domestic violence, paying more than 50% of household gross income for rent, or having insufficient household resources to pay for current housing and meet other basic needs.

Not homeless or at risk of homelessness

Please indicate any other necessary or relevant information about applicant:

Referring Agent Name:(Required)

Date:(Required)

Month

Day

Year

Referring Agent Signature:(Required)

Upload any additional documents

Max. file size: 50 MB.

Client Questionnaire: Help us understand more about you and the services/support you are seeking. Please note that your answers to this questionnaire will not impact HVMHC's decision on admission.

Why would you would benefit from living here?

What do you hope to get from living here?

What is your current living status and what is it like there?

What are some of your mental health symptoms?

How do they impact your daily life?

What are some of your goals relating to your mental health?

Do you have a history of substance use? If so, please explain.

Please write a statement briefly describing any other information you think is applicable to this application:

Upload any additional documents

Drop files here or

Max. file size: 50 MB.

By signing below, you as the applicant/client confirm that are willing to comply with the following expectations of Adult Housing Services:

Take and fill medications as prescribed

Follow program expectations

Follow the orders/terms of your probation/parole/commitment/Jarvis

Follow the terms of your lease (HBL only)

Applicant’s Name:(Required)

Date:

Month

Day

Year

Applicant's Signature

Housing Services Application