Application for Rapid Re-Housing Rapid Rehousing Application 1Locations2Eligibility3Household4Housing Situation5Finances6Challenges7Challenges8Program Rules9Releases Hillcrest cooperates with other agencies in Region 4 of the Missouri Balance-of-State CoC and the Saint Joseph CoC for Coordinated Entry -- a process where agencies in a region work from one combined list of households in need of housing assistance. Participating in this process is optional. If you have already completed this application, and just need to schedule an assessment call, reach out to Carmel Wilson at 816-866-6119. First choice for housing location* Clay/Platte Counties, Missouri (Liberty, Gladstone, KC North, etc.) Cameron, MO & surrounding areas (Clinton, Caldwell, Daviess Counties) St. Joseph, MO (Buchanan & Dekalb Counties) Maryville, MO (Nodaway County), or others in far Northwest Missouri Chillicothe area in North-Central Missouri Kansas City (Jackson County, MO / Wyandotte County, KS) ** Overland Park and surrounding (Johnson County, KS) ** Hillcrest Transitional Housing sites (Independence, MO; Lee's Summit, MO; Kansas City, KS; Overland Park, KS) ** Other areas you are interested in finding housing Clay/Platte Counties, Missouri (Liberty, Gladstone, KC North, etc.) Cameron, MO & surrounding areas (Clinton, Caldwell, Daviess Counties) St. Joseph, MO (Buchanan, Andrew, & Dekalb Counties) Maryville, MO (Nodaway County), or others in far Northwest Missouri Chillicothe area in North-Central Missouri KCMO / Jackson County, MO ** Other areas in Missouri KCK / Wyandotte County, KS ** Overland Park / Johnson County, KS ** Somewhere else in the US Far Northwest Missouri - Other Service Organizations Hillcrest is a “front-door” agency for other service providers in this area. Our organization DOES NOT provide services in these counties: - Atchison, Holt, Nodaway, Andrew, Worth, Gentry, Harrison If you would like to work with us for initial interviews, or are also considering other areas, please continue with this application. Otherwise, we recommend working with Catholic Charities 816-232-2885 / 1-888-629-2886 1123 S 10th St / St Joseph, MO 64503 https://www.catholiccharities-kcsj.org/in-st-joseph Some areas you selected require a different assessment process with another agency Please make note of the Access Hubs listed below for "Coordinated Entry" in other parts of the Kansas City metro area. Contact those agencies separately after you've completed this application here for housing programs in the KC Northland and Northwest Missouri, Kansas City - Other Intake Organizations Our organization provides some services in these counties. However, applying for Rapid Rehousing in these areas should start with the agencies listed below. You can also start the screening process by calling United Way's 2-1-1. Jackson County Resource Hubs reStart Housing Solutions / 816-472-5664 / 1444 E 8th St, KCMO 64106 Community LINC / 816-531-3727 / 4012 Troost, KCMO 64110 Community Services League / 816-491-2013 / 404 N Noland Rd, Independence, MO 64050 Kansas City VA Medical Center / 1-877-424-3838 / 4801 E Linwood Blvd, KCMO 64128 Wyandotte County Resource Hubs Frank Williams Center / 913-233-3329 / 1201 N 7th St, KCK 66101 Overland Park - Other Intake Organizations Our organization does provide Rapid Re-Housing services in this area. Unfortunately, we are not an intake agency in this area. Please start with one of the following agencies for housing services in Johnson County, Kansas: Salvation Army / 913-782-3640 / 420 E Santa Fe, Olathe, KS 66061 Catholic Charities / 913-384-6608 / 9806 W 87th St, Overland Park, KS 66212 Transitional Housing Sites Our Transitional Housing programs, located in Independence, MO, Lee's Summit, MO, and Kansas City, KS, use a different application. Please complete our separate application for Family & Adult Transitional Housing. The Hillcrest Transitional sites in Liberty, MO, and Avondale, MO, are operated by a separate organization: Hillcrest Hope. The Hillcrest Transitional sites in Platte City, MO, and Parkville, MO, are operated by a separate organization: Hillcrest Platte County. The former Hillcrest Transitional sites in St. Joseph, MO, are operated by a separate organization: Pivotal Point. Were you referred to Coordinated Entry (CE) by a Public Housing Authority?* Yes No Where are you living right now?* In a car or other vehicle Emergency shelter Domestic violence shelter On the street, in a park, or other place not meant for human habitation In a house/structure without adequate bathroom, kitchen, or utilities (water, electric, heat) Transitional housing program In a hotel that a charity/government paid for (no self pay) In a hotel paid for by myself, family, or friends ** Staying with family or friends ** Facing eviction (notice received, hearing scheduled) ** Are you currently fleeing, or attempting to flee, domestic violence?* Yes No You are currently not eligible for this program. Because our program is funded in-part by federal HUD grants, we are only able to accept those who are “Literally Homeless” (living in a vehicle, shelter program, park, street, or other place not meant for human habitation), or those who are fleeing domestic violence. If your situation changes, please apply at that time. You may want to consider applying for our Transitional Housing program, which has more flexibility on what qualifies as homeless. Also, look through our list of Emergency Resources for other agencies which may have services that better align with your immediate needs. Keep in mind that our program is not an emergency shelter and our programs do have waiting lists. These service agencies can help you with safety planning. Rose Brooks816-861-6100Kansas City, MO Synergy Services816-321-7050Kansas City Northland Green Hills800-942-0649Cameron & Trenton, MO Friends of Yates913-321-1566Kansas City, KS Hope Haven816-380-4663Harrisonville, MO Hope House816-461-4673Independence & Lee's Summit, MO New House816-471-5800 Safe Haven816-452-8535 We highly recommend working with a domestic violency agency to address specific needs that they are more equipped to handle. You can still continue applying for our housing program either way. Applicant InformationHiddenEligible for Youth-RRHCalculated if either applicants' age is 17-24 Applicant Name* Applicant Age*Please enter a number from 0 to 150.Applicant Phone*Applicant Email If you are concerned about domestic violence, someone stalking you, trying to find you, etc., Please consider whether the person you are fleeing may have access to this email address. You may want to create a new email address. Applicant Marital StatusSingleMarriedUnmarried CoupleDivorcedSeparatedWidowed/WidowerHave you served in the US Military? If so, when and what branch?* Is there a co-applicant (spouse / significant other)? Yes No Co-applicant InformationCo-Applicant Name* Co-Applicant Age*Please enter a number from 0 to 150.Co-Applicant PhoneCo-Applicant Email Co-Applicant Marital StatusSingleMarriedUnmarried CoupleDivorcedSeparatedWidowed/WidowerHas co-applicant served in the US Military? If so, when and what branch?* Household MembersPlease list EVERYONE (adults & children) who would be living in your household:*Remember to include YOURSELF in this list of household members!NameRelationshipDate of BirthSS# (last 4 only)GenderRace(s)Hispanic (Y/N) Did you add everyone in your household to this list, including yourself?Has any member of your household been diagnosed with a disabling condition?Include permanent, temporary, or past conditions that have affected activities of daily living, even if they are not active now. Disabling conditions include physical, emotional, psychological, & developmental disabilities, as well as chronic substance or alcohol abuse. These do not have to prevent you from working to count as a disability - just anything that can interfere with or disrupt your daily living (example: chronic asthma, anxiety disorder, past substance abuse, etc.).NameDisabling ConditionRequires help with Daily ActivitiesOther Information You would like to Share Is Anyone Pregnant? Yes No When is the due date for the pregnancy? Your Address or Usual Location*If you don't have a physical address, use a description of your general location, the nearest major intersection, or the name of the city where you stay or park most often.How long have you lived at this address/location? Have you been asked to leave your current living situation?* Yes No If Yes, when will you be required to leave? Have you ever participated in the Hillcrest Transitional or Rapid Re-Housing Programs before? Which location?*If so, WHEN and WHICH housing site or office location did you work with? How did you hear about Hillcrest? When did you last have your own stable housing (month/year), and how long did you stay in that housing? Where have you been living (or sleeping) since then?In a few short sentences, explain the reasons that led to your current situation. What things caused your homelessness or your current housing crisis?*Please list any Emergency Contacts we can use if we are unable to reach you.First and Last NameAddress, City/StatePhoneRelationship Are you currently working?* Yes No Permanent Disability About how many hours are you working each week? Is Co-Applicant currently working? Yes No Permanent Disability About how many hours is Co-Applicant working each week? Do you have your own vehicle? Yes No Is your vehicle running, fully licensed, and currently insured?If any of these is "no", please specify. Please list sources of income for your household(Jobs, Disability Benefits, Food Stamps, Child Support, Retirement, etc.)Type of Income/SourcePerson receiving incomeRate of Pay ($/hr)Amount per Month List any money you owe for past evictions, past-due rent, unpaid utility bills, or other housing/utility costs.Any debts that may prevent you from being approved for your own housing should be included here.Type of Bill/DebtPlace/CompanyAmount DueMonthly PaymentPast Due? (Yes/No) Other Challenges - Primary ApplicantDo you use drugs or alcohol? Yes No Have you ever been in drug or alcohol rehabilitation? Yes No If Yes, When? What is the name of abused substance? What rehabilitation facility did you attend? Are you an AA participant? Yes No Are you an NA participant? Yes No Have you ever been arrested? (DWI, Bad Checks, Assault, etc.) Yes No If Yes, when and for what? Did you receive a fine/sentence? Yes No Not yet resolved Have you been a battered person? Yes No If Yes, when were you battered? Have you served any time in jail? Yes No If Yes, when, and how long were you in jail? Do you have any pending or outstanding tickets? (speeding, parking, etc.) Yes No If Yes, what were the pending tickets for? When is/was your court date? Are you on parole or probation right now? Yes No If Yes, How long? Parole/Probation Officer's Name Parole/Probation Officer's Phone Number Is there a warrant(s) out for your arrest right now? Yes No If Yes, Reason for Warrant(s) Other Challenges - Co-ApplicantDoes co-applicant use drugs or alcohol? Yes No Has co-applicant ever been in drug or alcohol rehabilitation? Yes No If Yes, When? What is the name of abused substance? What rehabilitation facility did co-applicant attend? Is co-applicant an AA participant? Yes No Is co-applicant an NA participant? Yes No Has co-applicant ever been arrested? (DWI, Bad Checks, Assault, etc.) Yes No If Yes, when and for what? Did co-applicant receive a fine/sentence? Yes No Not yet resolved Has co-applicant been a battered person? Yes No If Yes, When was co-applicant battered? Has co-applicant served any time in jail? Yes No If Yes, when, and how long was co-applicant in jail? Does co-applicant have any pending or outstanding tickets? (speeding, parking, etc.) Yes No If Yes, what were the pending tickets for? When is/was co-applicant's court date? Is co-applicant on parole or probation right now? Yes No If Yes, How long? Parole/Probation Officer's Name Parole/Probation Officer's Phone Number Is there a warrant(s) out for co-applicant's arrest right now? Yes No If Yes, Reason for Warrant(s) Hillcrest Rapid Rehousing Program RulesBy submitting this application, I agree that the preceding information is true and accurate to the best of my knowledge. The following rules of conduct shall be in effect while clients participate in the Hillcrest Rapid Re-Housing Program. Violation of any rule will, at the discretion of the Board or the Staff, be cause for immediate dismissal from the program. Hillcrest Services: No illegal activity of any kind will be permitted at Hillcrest properties/service sites. All adults in the program are expected to find and/or maintain income which will sustain permanent housing – including employment, SSI, SSDI or a combination of sustainable income sources. All adults must attend scheduled meetings and appointments. Rental Lease Terms: Any new lease you enter into is between you and the landlord; Hillcrest is not a party to your lease agreement and is not liable for any fees you may incur outside of the unrelated Hillcrest/Landlord Agreement. Follow the rules of the lease: -- No fighting of any kind will be tolerated. -- No illegal activity including the use of illegal substances will be permitted. -- Follow lease policies regarding pets, smoking, overnight guests, trash etc. Rental unit must be kept clean and free of clutter. I have read and understand that If I violate any one of these rules I may be dismissed from the Hillcrest Rapid Re-Housing Program. I also understand that I may be asked to leave the program at any time for any other reason. I agree not to hold Hillcrest and/or any other persons associated with the program responsible/liable, singly or collectively, from injury, misadventure, harm, loss, inconvenience or damage sustained as a result from participating in this program. I give permission for information to be released about myself and my children by or to any doctor, social worker, counselor, employer, current/former/future landlord, current/former/future vendor (utility companies, law firms, collection agencies, etc.), shelter or agency as deemed necessary by Hillcrest. I give permission for information about myself and my children to be entered into the local homeless management information system, including but not limited to MAAClink, CaseWorthy, and/or ICA-ServicePoint. I agree that my acceptance into the Hillcrest Rapid Re-Housing Program is not a landlord agreement or guarantee of fund assistance, but an application to receive supportive housing services and possible financial assistance provided by Hillcrest. Do you agree to our program rules?* I have read and understand the program rules and I/we agree to abide by them. Do you consent to Hillcrest sharing your information where Hillcrest deems it necessary?* I give permission for my/our information to be shared as described. St Joseph Area - Information SharingIn the St Joseph area (Buchanan, DeKalb, and Andrew counties), several agencies work together from the same list of people and families to address needs for housing assistance. If you've completed an assessment with one agency, you're on the list to work with the first agency that has an opening in their program that meets your needs. Some of the agencies that are able to do this assessment include: Community Action Partnership (CAP) Catholic Charities 8th Street Drop-In Center / Community Mission (CMC) InterServ Northwest Health Services Salvation ArmyHave you completed an assessment with one of these service agencies?* Yes No Not Sure Do you consent for your information to be shared with other service agencies in the St Joseph area, and for your information to be entered in the MAAClink system?* Yes, I give permission for my/our information to be shared in the St Joseph area as described. No, do not share my/our information. Missouri Balance of State - Information ReleaseHillcrest is part of a group of coordinating agencies called the Missouri Balance of State Continuum of Care. (moboscoc.org) We cooperate with agencies in this group throughout the state of Missouri for the purpose of furthering services and housing. To make it easier for clients to move between regions and agencies, we've all agreed to use the same assessment and to share the same secure database for client information. In order to work with other agencies, we need to get your permission to store your information in a secure database that is shared by participating agencies in our group. The information on this page is a summarized version of full "Informed Consent" for storing your information, and the "Release of Information" for sharing your information. This authorization to share information would remain in effect for 12 months unless it is revoked in writing. You can contact us at any time to change the level of information we share about you. You may request a list of participating agencies before agreeing to share your information. The latest membership list can be found at moboscoc.org/membership. Types of information that might be shared include: Personal identifying information (names, date of birth, gender) Past or current participation in housing and supportive service programs Contact information Information about military service and VA eligibility Housing history and housing status Household income, financial assistance and sources Disability information We use a secured database that is shared by other agencies throughout the state of Missouri*All of our partner agencies, and all individuals who would see any shared information, have signed agreements to treat your household's information in a a professional and confidential manner. I CONSENT to having my/our information entered into a shared computer system. I DO NOT agree to have my/our information entered in a shared computer system. I will discuss other options by phone (such as, Hillcrest keeping paper files) Please select your preferred level of disclosure and participation in Coordinated Entry:*I authorize Hillcrest to share the following information about me and my household members during case conferencing in order to determine eligibility for housing openings... SHARE ALL ELIGIBILITY INFORMATION. Age, gender, veteran status, disability status, household size, desired geographic location of housing placement, mental health information, current or past substance use, developmental disability/traumatic brain injury diagnosis, and HIV/AIDS status. SHARE ONLY LIMITED ELIGIBILITY INFORMATION. Age, gender, veteran status, disability status, household size, and desired geographic location of housing placement. OPT-OUT OF COORDINATED ENTRY. I do not want to be considered for housing opportunities via Coordinated Entry. I understand that I will not be considered for housing openings available through the Coordinated Entry System. I'd like to discuss these options later, during the phone assessment Please select how you would like to be identified with other agencies during case conferencing:* USE MY/OUR NAME. I authorize my name (and the name of my household members) to be included in the database of clients seeking housing via Coordinated Entry. In the event that I cannot be located when a housing opening becomes available, my name (and the name of my household members) may be used during case conferencing to develop a plan for locating me to notify me of the opening. USE A CASE NUMBER. I DO NOT authorize my/our names to be included in coordinated entry. I understand that using a case number instead of names may limit participating agencies' ability to locate me and notify me of available openings. NameThis field is for validation purposes and should be left unchanged.