Appendix P: Referral Form

OMB Control # 0970 – XXXX

Expiration Date: XX/XX/XXXX

Appendix P: Referral Form

Referral Form

This information is being collected to refer a family to the Family Unification Program (FUP) and will be used to determine eligibility for FUP. This information is also being collected to inform the evaluation of the Family Unification Program (FUP) being conducted by a research team at the Urban Institute, Chapin Hall at the University of Chicago and Child Trends. This information will be used to inform the US Department of Health and Human Services Administration for Children and Families (HHS ACF) and the US Department of Housing and Urban Development to improve the administration of the FUP program. This form should be completed by staff at [REFERRING AGENCY]. All the information you provide will be kept private to the extent permitted by law

This form was based on several existing forms used by public child welfare agencies and on the eligibility information found in US Department of Housing and Urban Development’s (HUD) FY2010 FUP Notice of Funding Availability. The form may be revised to reflect updated eligibility information. Agencies may also reformat the form and add (but not remove) items as needed,

Referral Date:__________________________________

Child Welfare ID:_______________________________

Location of current residence (e.g. zip code, to be adapted to conform with each site’s housing authority requirements): ___________________________________

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to evaluate the effectiveness of the Family Unification Program. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB number and expiration date for this collection are OMB #: 0970-XXXX, Exp: XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Michael Pergamit at [email protected].

CONTINUED ON NEXT PAGE

Adults expected to live in the housing with FUP Voucher, including the voucher applicant
Child Welfare Person ID	Name		SEX (F or M)		DOB			Race*		Ethnicity (Hispanic or Latino)	Relationship to voucher applicant (e.g. boyfriend, mother, husband, sister)
											Voucher Applicant
Children expected to live in the housing with FUP Voucher
Child Welfare Person ID	Name	SEX (F or M)		DOB		Race*	Ethnicity (Hispanic or Latino)		Relationship to voucher applicant (e.g. biological child, adoptive child, niece/nephew)		Where is the child currently living? If in foster care, include the expected reunification date.
* Race responses (one or more may be written): White, Black or African American, American Indian or Alaska Native, Asian, Native Hawaiian, or Other Pacific Islander. CONTINUED ON NEXT PAGE

Child Welfare Involvement

Client has an open DCF child welfare case: Y ☐ N ☐

Case type (current): ☐ Reunification ☐Family Preservation

Current Living Situations

Where is the family currently living?

☐ Private house/apartment of own

☐ With friends or relatives

☐ In place not designed for sleeping accommodation for human beings (e.g. car, park, abandoned building, bus or train station, airport, camping ground)

☐ Emergency shelter

☐ Transitional housing

☐ Hotel or motel

☐ Residential substance abuse treatment*

☐ Hospital (includes psychiatric hospitals) *

☐ Jail/incarcerated*

☐ Other, specify*:

*If client is in an institution (Residential SA treatment, psychiatric hospital, jail/incarcerated):

Will the client have access to stable housing upon exit? Y ☐ N ☐

What is their discharge date:____/____/______ (MMDDYYYY)

Do any of the following describe the families current living situation? For each of the following, check Yes (Y), No (N), or Unknown (U)

Living in dilapidated housing

The unit does not provide safe and adequate shelter and in its present

condition endangers the health, safety or well-being of the family. Y ☐ N ☐ U ☐

The unit has one or more critical defects, or a combination of intermediate

defects in sufficient number or extent to require considerable repair or

rebuilding. Y ☐ N ☐ U ☐

Family is living in substandard housing

Housing unit does not have operable indoor plumbing. Y ☐ N ☐ U ☐

Housing unit does not have a usable flush toilet inside the unit for the

exclusive use of a family. Y ☐ N ☐ U ☐

Housing unit does not have a usable bathtub or shower inside the unit

for the exclusive use of a family. Y ☐ N ☐ U ☐

Housing unit does not have electricity, or has inadequate or unsafe

electrical service. Y ☐ N ☐ U ☐

CONTINUED ON NEXT PAGE

Do any of the following describe the families current living situation? For each of the following, check Yes (Y), No (N), or Unknown (U) [CONTINUED]

Housing unit does not have a safe or adequate source of heat. Y ☐ N ☐ U ☐

Housing unit should, but does not, have a kitchen. Y ☐ N ☐ U ☐

Housing unit has been declared unfit for habitation by an agency or

unit of government or in its present condition otherwise endangers the

health, safety, or well-being of the family. Y ☐ N ☐ U ☐

Family Is homeless

An individual or family with a primary nighttime residence that is a

public or private place not designed for or ordinarily used as a regular

sleeping accommodation for human beings, including a car, park,

abandoned building, bus or train station, airport, or camping ground. Y ☐ N ☐ U ☐

An individual or family living in a supervised publicly or privately

operated shelter designated to provide temporary living arrangements

(including congregate shelters, transitional housing, and hotels and

motels paid for by charitable organizations or by federal, State, or

local government programs for low-income individuals). Y ☐ N ☐ U ☐

An individual who is exiting an institution where he or she resided for

90 days or less and who resided in an emergency shelter or place not

meant for human habitation immediately before entering that

institution. Y ☐ N ☐ U ☐

An individual or family who will imminently lose their primary

nighttime residence provided that: (1) The primary nighttime

residence will be lost within 14 days of the date of application for

homeless assistance (2) No subsequent residence has been identified

(3) The family lacks the resources or support networks, e.g., family,

friends, faith-based or other social networks, needed to obtain other

permanent housing. Y ☐ N ☐ U ☐

An individual or family who is fleeing or is attempting to flee, domestic

violence, dating violence, sexual assault, stalking, or other dangerous or

life-threatening conditions that relate to violence against the individual

or a family member, including a child, that has either taken place within

the individual’s or the family’s primary nighttime residence or has made

the individual or family afraid to return to their primary nighttime

residence; AND has no other residence; AND lacks the resources or

support networks, e.g. family, friends, and faith-based or other social

networks, to obtain other permanent housing. Y ☐ N ☐ U ☐

CONTINUED ON NEXT PAGE

Do any of the following describe the families current living situation? For each of the following, check Yes (Y), No (N), or Unknown (U) [CONTINUED]

Family is living in an overcrowded unit

The family is separated from its child (or children) and the parent(s) are

living in otherwise standard housing unit, but, after the family is

re-united, the parents’ housing unit would be overcrowded for the entire

family and would be considered substandard. (A unit is considered to be

overcrowded if the head of household has to share a bedroom with an

individual that is not their spouse or significant other or there are more

than 2 people per bedroom.) Y ☐ N ☐ U ☐

The family is living with its child (or children) in a unit that is

overcrowded for the entire family and this overcrowded condition may

result in the imminent placement of its child (or children) in out-of-home

care. Y ☐ N ☐ U ☐

Family is living with a household member that could result in

placement of child or delay of discharge from placement.

Family is living in a unit where the presence of a household member

with certain characteristics (i.e., conviction for certain criminal

activities) would result in the imminent placement of the family’s

child, or children, in out-of-home care; or the delay in the discharge

of the child, or children, to the family from out-of-home care. Y ☐ N ☐ U ☐

Family is living in a unit not accessible to disabled child(ren)

Family is living in housing not accessible to the family’s disabled

child or children due to the nature of the disability. Y ☐ N ☐ U ☐

Past Living Situations

For each of the following questions, check Yes (Y), No (N), or Unknown (U)

Family has had at least one past episode of living in any of the following:

(a) on the street, in car, or other places not meant for habitation Y ☐ N ☐ U ☐

(b) emergency shelter, Y ☐ N ☐ U ☐

(c) transitional housing, Y ☐ N ☐ U ☐

(d) hotel/motel/SRO Y ☐ N ☐ U ☐

Has client been evicted or asked to leave housing? Y ☐ N ☐ U ☐

If yes, how many days before they need to vacate housing? _________________ # of days.

Has the family had 3 or more moves in past year? Y ☐ N ☐ U ☐

CONTINUED ON NEXT PAGE

Household Background

For each of the following questions, check Yes (Y), No (N), or Unknown (U)

Is one of the household members listed above a sex offender? Y ☐ N ☐ U ☐

Has anyone in the household been found to have manufactured or produced methamphetamine

on the premises of federally assisted housing? Y ☐ N ☐ U ☐

Has the voucher applicant ever had a termination of parental rights

(TPR) or termination of guardianship (TOG) for any children? Y ☐ N ☐ U ☐

Does the voucher applicant have a planned or pending TPR or TOG for

any children listed in the above household roster? Y ☐ N ☐ U ☐ Does the voucher applicant have any pending felonies or non-drug related

felony convictions? Y ☐ N ☐ U ☐

If yes, were any in the last 5 years? Y ☐ N ☐ U ☐

Does the voucher applicant have drug related charge for manufacturing,

sales, distribution or possession with intent? Y ☐ N ☐ U ☐

If yes, has the individual completed an approved drug rehab program? Y ☐ N ☐ U ☐

Is there a felony conviction for a violent crime within the past 3 years? Y ☐ N ☐ U ☐

If yes, has the individual completed an approved anger management

program? Y ☐ N ☐ U ☐

Has the voucher applicant ever been evicted? Y ☐ N ☐ U ☐

If yes, has the voucher applicant been evicted from a housing authority

property in the past 3 years? Y ☐ N ☐ U ☐

If yes, was there an eviction prior to 3 years ago but the voucher

applicant still owes money to the HA? Y ☐ N ☐ U ☐

Is any member of the household a citizen of the United States of America or a documented

immigrant? ☐ Adult ☐ Child ☐ No member of the household is a citizen

Is the applicant household’s income below 50% of the Area Median? ☐ Yes☐ No ☐ Unknown

Family Size	50% of Area Median Income
1	[FILLED OUT BASED ON SITE]
2
3
4
5
6
7
8
Over 8

Gross Annual Income: $___________________

Income includes wages, unemployment, TANF,

child support, etc. DO NOT COUNT FOOD STAMPS

Household members include all adults and

children in the residence

CONTINUED ON NEXT PAGE

Service Provision Plan

Who will be providing case management services for the family?

☐ Public Child Welfare Agency ☐ Other organization, please specify: _______________

How long will case management services be provided for the family?

☐ 6 months ☐ 12 months ☐Other, please specify number of months: ____________________

Which services will be provided or coordinated:

☐ Voucher application assistance

☐ Housing search assistance

☐ Housing move in assistance

☐ Monetary assistance (e.g. funding to pay off arears, pay application fee, security deposit, etc.)

☐ Adult education/employment

☐ Domestic violence services

☐ Child substance abuse treatment

☐ Adult substance abuse treatment

☐ Family or adult counseling

☐ Parenting education

☐ Self-Sufficiency

☐ Access to Benefits (SSI, WIC, SNAP)

☐ Day care

☐ Legal aid

☐ Health services

☐ Child counseling

☐ Money Management

☐ Other, please specify:___________________________________________________________

1