Participant Application

Step 1 of 7

YWCA Quincy's Permanent Supportive Housing Program is funded by the Department of Housing and Urban Development (HUD) under the Continuum of Care (CoC) Program.

Disability Status Documentation Requirements: For more information, see 42 U.S. Code § 11360. Definitions.

The referring professional should initial each line to indicate that you understand our program eligibility. To be eligible for the YWCA PSH program, a household must:

Initial

1. Enter PSH from literal homelessness (HUD Category 1) or must be fleeing domestic violence (HUD Category 4), AND*

Initial

2. Have a physical, mental, or emotional impairment, including an impairment caused by alcohol or drug abuse, post-traumatic stress disorder, or brain injury that meets the criteria found in (42 U.S.C. 11360(9)), AND

Is expected to be long-continuing or of indefinite duration;
Substantially impedes the individual’s ability to live independently;
Could be improved by the provision of more suitable housing conditions; and
Is a physical, mental, or emotional impairment, including an impairment caused by alcohol or drug abuse, post-traumatic stress disorder, or brain injury;
Is a developmental disability, as defined in section 15002 of this title; or
Is the disease of acquired immunodeficiency syndrome or any condition arising from the etiologic agency for acquired immunodeficiency syndrome.

Initial

3. Full or shared physical custody of a minor child, or will have full or shared physical custody of a minor child within 90 days. A limited number of units are available for households without children.

*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 also meets this criteria.

Verification of items 1, 2, and 3 above must be provided to the YWCA Quincy in order to make an eligibility determination. Options for professional verification include but are not limited to:

Homeless Status/Length of Time Homeless Verification: HMIS or comparable database record, written observation by outreach worker, documentation from hospital or other institution, etc.
Disability Verification: SSI check, Physician, nurse practitioner, LCSW, or other professional's completion of the Disability Documentation for Permanent Supportive Housing Program (available at YWCAQuincy.org), etc
Custody Verification: Legal custody agreement, divorce decree, DCFS family reunification forms, etc

Attention Director of Grant Coordination

Referring Agency(Required)

Contact(Required)

Phone(Required)

Email(Required)

HOUSEHOLD MEMBERS

(List the head of household first, spouse, then children)

First Name

Last Name

Gender

Age

DOB