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									            PERMANENT SUPPORTIVE HOUSING SUPPORT SERVICES - 2011
                              Scopes of Service

GRANTEE INFORMATION
Grantee:

P.O. Number:

Program Name:

Term of contract: January 1, 2011 through December 31, 2011

Contract amount:

GRANTEE CONTACT PERSON FOR THIS CONTRACT:
Name:
Phone Number:
E-Mail:
Mailing Address:
Aldermanic Ward:

BASIC PROGRAM OPERATION
Program Site Address:
Aldermanic ward of Program Site:

DAY OF OPERATIONS
            SUN           MON      TUES       WED         THU   FRI   SAT
FROM
TO

□ 24 HOURS 7 DAYS A WEEK

INTAKE HOURS
          SUN           MON      TUES         WED         THU   FRI   SAT
FROM
TO



CASE MANAGEMENT RATIO
(Minimum ratio for PSH programs (1:30)


Total planned Units of Service
Grantee Name
                                                                            1
            PERMANENT SUPPORTIVE HOUSING SUPPORT SERVICES - 2011
                              Scopes of Service


DESCRIPTION OF TARGET POPULATION




NUMBER OF CLIENTS AND HOUSEHOLDS TO BE SERVED
                                                Jan –       Apr-                               Total
                           Carryover from                              Jul-Sept   Oct-Dec
                                                 Mar        Jun                              (new plus
                              Dec 2010                                  (new)      (new)
                                                (new)      (new)                            carryover)
 Number of
 unduplicated clients to
 be served
 Number of
 unduplicated
 households to be served


OUTCOMES AND PERFORMANCE MEASURES
___ % of Households that remain housed for 12 months
(Describe activities that will be performed to achieve this outcome)



 85 % of Households without a reliable source of income at program entry will increase their income
within the first year through acquisition of benefits, employment, or a combination of both.
(Describe activities that will be performed to achieve this outcome)




MANDATORY ACTIVITIES
      Enter data into HMIS (program entry, services provided, program exit) within 24 hours of
       client interaction.
   Indicate name of program in HMIS and unique ServicePoint HMIS I.D. for this program




      Provision of/or linkage to physical health assessment, Psycho-social assessment, and linkage to
       mental health and/or substance abuse services and community based case management as
       appropriate
Grantee Name
                                                                                                     2
            PERMANENT SUPPORTIVE HOUSING SUPPORT SERVICES - 2011
                              Scopes of Service

      Perform benefits screening and linkage to mainstream resources
      Provision of/or linkages to supportive services that help promote residential stability , increase
       household skill level and/or income, and promote greater self determination


SUBMITTAL AND APPROVAL:

a) Applicant signature:
b) Name (typed)
c) Date submitted:


d) DFSS Staff signature :
e) Name (typed):
f) Date approved




Grantee Name
                                                                                                        3

								
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