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									                                                                                                               Form 1
Application and Serious Mental Illness (SMI) Verification

Applicant Information:
Print Name of Applicant (qualifying individual):

Gender:     M/F          Date of Birth:                    Social Security Number:

Current Contact Address (if applicable):

Current Contact Phone Number (if applicable):                               Message Phone:

Current E-mail Address (if applicable):

Applicant is:                                        Applicant has:
        Homeless                                             Health Condition that warrants special accommodation
        At-Risk of Homelessness                                  Wheelchair          Walker        Oxygen
                                                                 Other:

**Verification below to be completed by the supportive services provider/case manager.

  Verification of Serious Mental Illness or Severe Emotional Disturbance and DBH Program
Enrollment/Service Engagement: The applicant may provide records that document their eligibility OR they may
authorize DBH to contact a specific provider for verification. Documentation must include information that clearly states
the applicant meets the definition of serious mental illness (as defined in California Welfare and Institutions Code Section
5600.3 (b) (1)) or severe emotional disturbance (as defined in California Welfare and Institutions Code Section 5600.3 (a)
(1)) and the applicant is enrolled or engaged in services provided by DBH or one of its contracted mental health providers.




Name of Supportive Services Program/Agency:

Signature of Supportive Services Provider/Case Manager                    Date Completed

MHSA – Office Use

                  Diagnosis verified by Behavioral Health-MHSA                Approved         Denied
              Name:______________________________________                        Date: ______________
                                                                                                                                 Form 2
       Certification of Homelessness

   Instructions:
   Please provide certification which will verify and document your knowledge of an applicant being either…
     Continuously homeless for the past year – “Section A” to be completed by Facility/Shelter/Program.
     Having had at least 4 episodes of homelessness within the past 3 years of at least 15 days of homelessness per episode.
        - “Section B” must have written certification on Letterhead from Facility/Shelter/Program/and/or Case Manager for
        each episode.

Section A - Certification – Continuously Homeless for the past year
   I certify that                                          has been continuously homeless for the past year and living on the
                      (Applicant’s Name)
   streets and/or staying at an emergency shelter                                                       during the past year.
                                                          (Facility/Shelter/Program)
   Additional detail of the client being continually homeless for the past year (or longer) may be provided here.




   This Agency / Service Provider are classified as one of the following types of facilities / programs:
   
              Emergency Shelter                     Other: ______________


   Name of Agency                  Signature of Agency Staff             Tittle                            Phone                 Date

Section B - Certification – Four (4) Episodes of Homelessness within the past three (3) years
   I certify that __________________________ stayed at the following locations and/or on the streets for the following periods of time:
                      (Applicant’s Name)
   Example: Lifeline Shelter, Cleveland Between: 1/12/10 and 8/15/10

                                 Live At:                                                                          Check when
                                                                     Start Date         End Date
                    (Facility-Shelter/Program/Streets)                                                     Supporting Letter is attached.
   1)

   2)

   3)

   4)


   Additional detail of the applicant’s episodes of homelessness may be provided here.




   Before coming to this Facility/Shelter/Program, the homeless person resided at___________________________________.

   I                                     certify that I have met with my worker and that all of the above information is correct.
             (Applicant Name)

   Signature of Applicant: ________________________________             Date: ___________________


                                                                                      (    )
   Signature of Mental Health Staff/Case Manager          Title                       Phone                               Date
                                                                                                                                     Form 3
     Certification of At Risk of Homelessness

   Instructions:
   Please provide certification which will verify and document your knowledge of this applicant who due to housing instability,
   is at imminent risk of homelessness.
         Certification - “Section A” completed by Supportive Services/Agency.
         Self-Statement – “Section B” completed by Applicant.

Section A - Certification – At Risk of Homelessness
   I certify that                                                      due to housing instability, is at imminent risk of homelessness.
                               (Applicant’s Name)

   Current living situation:                                           How long did applicant stay at that place? _________________.

   Additional details of applicant’s living situation may be provided here.


   This Agency / Service Provider are classified as one of the following types of facilities / programs:

      Emergency Shelter                                 Correctional Facility                              Medical Institution
      Mental Health Institution                         Permanent Housing                                  Other: ______________
      Transitional Housing                              Substance Abuse Facility


   Name of Agency                 Signature of Agency Staff                Tittle                            Phone                Date

Section B - Applicant – Self-Statement of Homelessness / At Risk of Homelessness
   Prior history of housing within past year (check all that apply):
   Living in/ with
         Domestic Violence Situation                  Friends                                     Residential
         Emergency Shelter                            Hospital                                    Streets
         Exiting Child Welfare                        Hotel/Motel                                 Treatment Facility
         Exiting Juvenile Justice System              Local Jail                                  Other:
         Family

   What else would you like to share about your history? For example, “I can not remember the name of the place where I was living
   during the fall of 2011 but I believe that it was a homeless emergency shelter. I have problems with my memory from that time due to
   an illness.”




   I certify that I am, or was homeless, or at risk of homelessness as identified above.

   Signature of Applicant: ________________________________                Date: ___________________
    MHSA – Office Use
                                At-Risk of Homelessness verified by Behavioral Health-MHSA
                       Approved            Referred for Imminent Risk of Homelessness Review                         Denied
                    Name:______________________________________                                 Date: ______________
                         Reviewed for Imminent Risk of Homelessness                        Approved           Denied
     ____________________________, Karen Markland, MHSA - Division Manager                                     Date: _____________

								
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