Sweetwater Family Resource Center Application | Sweetwater Family Resource Center

Applicant Name

Today's Date

Homeless?

Physical Address

Street Address

City

State

Zip Code

Mailing Address

(If different from physical address)

Address

City

State

Zip Code

Email Address

Phone

Someone who will know how to reach me is:

Who referred you to us for assistance?

Driver's License or ID Card

Upload requirements

Children's Birth Certificate(s)

Upload requirements

Proof of Income (if any)

Upload requirements

For what type of assistance are you applying?

Rent

Fuel

Utilities

Food

Transportation

Other (please specify)

Do you have an Eviction Notice or Past Due Notice?

Yes

Please attach proof of a job or medical appointment that you need fuel assistance for

Upload requirements

Please attach a copy of your current driver's license

Upload requirements

Please attach a copy of your current car insurance

Upload requirements

Please attach a copy of your current car registration

Upload requirements

Please attach a copy of your past due utility bill

Upload requirements

Please list your reason for transportation (location & time)

Have you applied for SNAP benefits?

Yes

Other Information

Please explain what happened that created a need for you to apply for assistance?

Have you been affected by COVID-19?

Yes

Household Members

How many individuals are in your household?

Please complete the information for ALL household members (including yourself)

Verification

I hereby verify that my answers on this application are truthful. I understand that funds are limited, an eligibility is not a guarantee of assistance. I understand that eligibility includes income, need, provision of required documents, and the requirement to take "One Step Forward". I understand that any expectations or extensions will be at the sole discretion of the Sweetwater Family Resources Center (SFRC), and that I may be required to update information following assistance.

I understand that I may be contacted in the months following assistance. I agree to respond to calls and requests for information from the Sweetwater Family Resources Center about my experience and my situation following assistance.

I authorize SFRC to verify the information contained in this application, and I authorize those contacted by SFRC to provide the information requested. I have had an opportunity to the HMIS Privacy Notice. I agree to hold harmless those persons and agencies providing information, as well as the Sweetwater Family Resources Center and its staff members.

Signature (Applicant)

Printed Name

Date

Signature (Spouse or Other Adult)

Printed Name

Date

Self-Declaration of Income

Please initial next to the choice that best describes you. (adults only)

I certify, under penalty of perjury, that I currently receive the income indicated above.

I certify, under penalty of perjury, that I do not have any income from any source at this time.

Signature (Applicant)

Date

Signature (Spouse or Other Adult)

Date

SFRC Consent for Release / Exchange of Confidential Information

I / We

authorize the Sweetwater Family Resource Center (SFRC) Independence and PATH Case Managers to exchange and release information with the following agencies to engage in verbal and/or written communication regarding my family and I. Pertinent records and information can be released between agencies as necessary for comprehensive assessment, service provision, monitory services, research, and case management.

Department of Family Services
Landlord(s) / Property Manager(s)
Legal Counsel
Mental Health / Substance Abuse Treatment Facility / Group Home
Physician, Dentist, or Hospital
Probation and Parole
Public Health and Best Beginnings Coordinator
School District #1 and/or District #2
Southwest Counseling
Sweetwater County Detention Center
Sweetwater Family Resource Center
Utility Companies

The following records and / or information may be exchanged:

Case plans
Financial needs
Healthcare information
Progress reports / services, notes / discharge reports
Social development / history
Other information to coordinate / facilitate services

For the purpose of case management services that will assist with:

Financial resources to maintain housing or placement into housing
Stabilization services to maintain current housing or placement into housing
Coordinated services planning with my household and the SFRC Staff
Referrals to other community services that will support my household / family

I have been informed that I may, in writing to the SFRC Case Managers, revoke this consent for release / exchange of information at any time and this may affect my continued eligibility.

Unless otherwise indicated, this consent for the release / exchange of information indicated above will be valid for the a period of one year from the date of signature for the ESG Homeless Prevention / Rapid Re-Housing / Emergency Shelter, CSBG, TANF, or PATH program(s) and Salvation Army.

Wyoming Homeless Collaborative

What is WHC Coordinated Entry? How will my information be used?

WHC Coordinated Entry is a collaboration through which participating agencies collectively measure and plan for the needs of individuals and families experiencing homelessness in Wyoming.

With your permission, you will be assessed by a staff person or volunteer for an agency that participates in WHC Coordinated Entry. The results of your assessment will be entered into a database called the Homeless Management Information System (HMIS).

You have the right to decline to participate. If you opt to participate, your assessment results will be provided to the Coordinated Entry Team -- a multidisciplinary team that facilitates referrals to several housing projects. If a project opening is identified for which you are potentially eligible to be prioritized, attempts will be made to reach you at the contact information you provide so that you can undergo project-level assessment.

Homeless Prevention Services: Assessment for homeless prevention services may or may not be assessed through the coordinated entry process.

What agencies currently participate in some aspect of WHC Coordinated Entry?

Campbell County YES Transition in Place (TLP)
COMEA Shelter
Community Action of Laramie County
Community Action Partnership of Natrona County
Community Connections

Council of Community Services
Fremont Good Samaritan Rescue Mission
Recover Wyoming
Seton House
Sweetwater Family Resource Center

Teton County Good Samaritan Rescue Mission
United Way 211
Volunteers of America - Northern Rockies
Veterans Administration - Cheyenne
Wyoming Rescue Mission

How do I opt to release (or not release) my information for purposes of WHC Coordinated Entry? (Check the box that applies)

Yes, I release my information to participate in WHC Coordinated Entry as it has been described to me.

No, I do not release my information to participate in WHC Coordinated Entry as it has been described to me.

Print Your Full Name

Date of Birth

Sign to certify the designation you have made

Today's Date

Wyoming Homeless Collaborative

Consumers Informed Consent & Sharing of Information Authorization

I/We

and

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 effectiveness of services provided. Participation in data collection is a critical component of our community's ability to provide the most effective services an 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 confidentiality 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.

List all Dependent Children, under 18, in the household, if any:

First and Last Name

Date of Birth

First and Last Name

Date of Birth

First and Last Name

Date of Birth

First and Last Name

Date of Birth

First and Last Name

Date of Birth

First and Last Name

Date of Birth

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 info an HMIS Agency Participant 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 this information is for assessing my/our needs for housing and other services.

I give permission for the following Personal Protection Information (PPI) to be shared in HMIS for any service project.

I do not give permission for the following Personal Protection Information (PPI) to be 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)

I give permission for the following information to be shared in HMIS for any service project.

I do not give permission for the following information to be shared in HMIS for any service project.

Homeless History
Family Composition
Income/Non-cash
Domestic Violence
Entry/Exit Information

Disabling Condition
Housing Information
Health Insurance Status
Measurement Score (VI-SPDAT)

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 confidentiality 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; I my revoke authorization at any time. If I revoke my authorization, all information about me already in the database will remain.

This release will remain in effect for 1 year from the date this ROI is signed.

Auditors or funders who have legal rights to review the work of this agency may see my information in HMIS related to the services I received and funded by their Department(s).

Client Signature

Date

Client Signature

Date

ESG House Options and Resources Eligibility

"But For" Certification

Applicant Name

This document is to certify that the above-named applicant or household has explored all re-housing options and all available resources. The case manager also certifies that a comprehensive assessment was completed and that the findings are such that the above-named applicant or household would become or remain homeless but for ESG Homelessness Prevention or RRH assistance.

Client Certification

Under penalty of perjury I,

affirm the following statements to be true.

I affirm that I have explored all housing options (family, friends, public housing, private housing) and that I have not been able to secure housing.
I affirm that I have accurately reported my family composition and total family income.
I affirm that my household lacks the financial resources and support networks needed to obtain immediate housing (i.e. start-up costs, etc).
I affirm that I am not receiving financial assistance for the same reason that I am applying for ESG funds.
I affirm that I would become or remain homeless but for ESG assistance.

Applicant's Signature

Date

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