Referral Form for Partners – Project Homekey Mendocino

We accept referrals from all organizations in Mendocino County that work with households that are homeless or at-risk of homelessness.

Our Project Homekey funding requires us to provide transitional and/or permanent housing to households experiencing homelessness or at risk of homelessness. For this reason, referrals expire after 90 days.

If you would like a household to remain on our Interest List, please submit a new referral every 90 days.

Today's Date(Required)

MM slash DD slash YYYY

Section 1: Referring Partner Agency

Your Name(Required)

Agency Name(Required)

Phone Number(Required)

Email(Required)

Section 2: Household Residents

Please let ALL possible household residents. **People who are not listed on this form cannot live in the unit.**

Name: Head of Household(Required)

First Last

Birthdate(Required)

MM slash DD slash YYYY

HMIS Number

Gender Identity(Required)

Head of Household Phone Number

Head of Household Email

Add a 2nd household member?

Yes

Name: Household Member 2

First Last

Birthdate

MM slash DD slash YYYY

HMIS Number

Gender Identity

Add a 3rd household member?

Yes

Name: Household Member 3

First Last

Birthdate

MM slash DD slash YYYY

HMIS Number

Gender Identity

Add a 4th household member?

Yes

Name: Household Member 4

First Last

Birthdate

MM slash DD slash YYYY

HMIS Number

Gender Identity

Estimated Household Monthly Income(Required)

Income Source(s)(Required)

Section 3: Please Tell Us About This Household

Where is this household currently living?(Required)

Please tell us about this household(Required)

Section 4: Please Answer These Questions About This Household

1. Does the household need interpretation/translation services?(Required)

Yes

In what language?

2. Does any member of the household have mobility concerns?(Required)

Yes

Do they need:

A downstairs room

An ADA room

3. Does the household include a service or emotional support animal?(Required)

Yes

I don't know

4. Does the household hope to include a domestic pet on the premises?(Required)

Yes

I don't know

How many and what breed of domestic pet?(Required)

5. Is the household in possession of a rental assistance voucher?(Required)

Yes

I don't know

What type of voucher?(Required)

When does it expire?

MM slash DD slash YYYY

6. Has any member of the household been convicted of manufacturing or producing methamphetamine?(Required)

Yes

I don't know

7. Does any member of the household have a recent history of violent criminal behavior which may have threatened the health and safety of another individual?(Required)

Yes

I don't know

8. Is any member of the household a registered sex offender?(Required)

Yes

I don't know

9. Has any member of the household been convicted of arson?(Required)

Yes

I don't know

10. Is any member of the household on supervised probation or parole?(Required)

Yes

I don't know

Are there "search and seizure" conditions as part of the probation/parole terms?(Required)

Yes

I don't know

Section 5: Priority Scoring Factors

At least one of the members of the household is:(Required)

An adult who has physical custody and parental rights of a child who is living with them.

A veteran

A senior (over the age of 60)

Has a complex medical or behavioral health condition

Fleeing domestic violence

A client of Adult Protective Services (APS)

A client of Child Welfare Services (CPS)

None of the above

Name of the veteran(Required)

Name of the senior(Required)

Describe the medical condition(Required)

Name of the person fleeing domestic violence(Required)

Name of the APS client(Required)

Name of the CWS client(Required)

Section 6: Partner Agency Support

Services your organization will continue to provide to this household:(Required)

Case management

ECM or Community Supports services

Permanent housing placement/support

Probation/parole supervision

Substance use treatment

Other service

None

Date enrolled in ECM or CS services

MM slash DD slash YYYY

Expected end date of probation/parole supervision

MM slash DD slash YYYY

Other service to be provided

Section 7: Verification of Housing Status

Select Household Type(Required)

Adult Household (without minor children)

Family with Minor Children

Transitional Age Youth (TAY) Age 18-24, Not Living with Parents

Adult Households (without minor children)

Review these housing categories and select all that apply.

Literally Homeless (1H)

Does not have a regular place to sleep, AND

Living in a place not meant for people to live in (car, garage, storage unit, unsafe structure, etc.)

Living in a homeless shelter or transitional housing

Staying in a hotel/motel PAID FOR by a program

Exiting an institution (jail, rehab, in-patient facility, etc.) where they stayed for FEWER THAN 90 DAYS and was homeless prior to entering the institution

Description of place not meant for people to live in

Name of homeless shelter or transitional housing

Name of program paying for the hotel/motel

Name of the institution they are exiting

Date of entry

MM slash DD slash YYYY

Date of exit

MM slash DD slash YYYY

Imminent Risk of Homelessness (2H)

Does not have enough resources to obtain permanent housing, AND

Housing will be lost because of eviction and hasn't secured other housing (verification needed: Eviction Notice or Pay or Quit Notice)

Fleeing or Attempting to Flee Domestic Violence (4H)

Does not have enough resources to obtain permanent housing, AND

Currently fleeing domestic violence

Attempting to flee domestic violence (staying with the abuser)

Staying in a domestic violence shelter

How long ago the abuse occurred

Name of domestic violence shelter

Family with Minor Children

Review these housing categories and select all that apply.

Transitional Age Youth, Age 18-24, Not Living with Parents

Review these housing categories and select all that apply.

Literally Homeless (1H)

Does not have a regular place to sleep, AND

Living in a place not meant for people to live in (car, garage, storage unit, unsafe structure, etc.)

Living in a homeless shelter or transitional housing

Staying in a hotel/motel PAID FOR by a program

Exiting an institution (jail, rehab, in-patient facility, etc.) where they stayed for FEWER THAN 90 DAYS and was homeless prior to entering the institution

Description of place not meant for people to live in

Name of homeless shelter or transitional housing

Name of program paying for the hotel/motel

Name of the institution they are exiting

Date of entry

MM slash DD slash YYYY

Date of exit

MM slash DD slash YYYY

At-Risk of Homelessness (1AR)

Does not have enough resources to obtain permanent housing, AND does not have resources or support to prevent homelessness, AND

Has been asked to leave (in writing) within 21 days

Does not have a lease and has been asked to leave (in writing)

Is staying in a hotel/motel that is NOT paid for by a program

Is exiting an institution (jail, rehab, in-patient facility, etc.) after MORE THAN 90 DAYS

Name of the institution they are exiting

Date of entry

MM slash DD slash YYYY

Date of exit

MM slash DD slash YYYY

Imminent Risk of Homelessness (2H)

Does not have enough resources to obtain permanent housing, AND

Housing will be lost within 14 days and hasn't secured other housing and has a court-ordered Eviction Notice

Other Homeless (3H)

Does not have enough resources to obtain permanent housing, AND

Has not had permanent housing in the past 60 days, and have moved 2 or more times in the past 60 days because of economic hardship and will need to move again

Is in a one-room studio (no bedrooms) with more than two people

Is in an overcrowded home (doubling up)

Number of adults in the studio

Number of children in the studio

Number of bedrooms in in the overcrowded home

Number of adults in in the overcrowded home

Number of children in the overcrowded home

Description of the family's housing situation

Fleeing or Attempting to Flee Domestic Violence (4H)

Does not have enough resources to obtain permanent housing, AND

Currently fleeing domestic violence

Attempting to flee domestic violence (staying with the abuser)

Staying in a domestic violence shelter

How long ago the abuse occurred

Name of domestic violence shelter

TAY Youth, age 18-24 (HNMP)

Does not have enough resources to obtain/maintain permanent housing, AND

Is an Unaccompanied Youth, age 25 or younger, who is not staying with anyone over age 25

Is a Former Foster Youth

Is homelsss or at-risk under other categories

Child Welfare (BFH)

Is experiencing housing instability, AND

Has a child with a CPS (FCS), or ICWA case

Has a foster child living in the home through a CPS (FCS) or ICWA placement

Is homeless or at-risk under other categories

Their housing was determined unsuitable for kids by FCS

Certification

I certify that(Required)

The household member has self-attested that the category indicated on this Verification of Housing Status is their current housing situation, and that the primary household member understands that demographic information about their household will be entered into the homeless management system, HMIS database.

I have reviewed the information and indications in this form submission with the primary household member.

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