H.O.U.S.E.

PROGRAM
(Helping Others Until Self-Empowered)

Catholic Social Services
Diocese of Fall River, Massachusetts

H.O.U.S.E. PROGRAM
The H.O.U.S.E. Program is an emergency shelter
program that is contracted to provided a safe temporary
emergency shelter to families referred by the
Department of Housing and Community Development
(DHCD) under the Emergency Assistance (EA) Program
of the Commonwealth of Massachusetts.

H.O.U.S.E. PROGRAM
The EA Shelters are apartments that are located within the
communities of our service area. The apartments are leased
and maintained through Catholic Social Services.
Each apartment has 3 bedrooms,
and is leased for a family of 6. The
apartments are completely furnished
and have all the basic requirements
needed for a homeless family to arrive
at the shelter at a moment’s notice.

H.O.U.S.E. PROGRAM
Intake and Triage

Intake Admission Data Form
HMIS DATA ENTRY ____________

HMIS EXIT ENTRY ___________________

Housing Specialist: ___________________

SS Location: _________________________________

Head of Household:
Entry Date: _____________DTA Office: ________________DTA Case Worker_______________
First: ________________________Middle:___________________Last:____________________
DOB: __________________ SS# ____________________ Phone #_______________________
M / F/Transgender

Health Insurance Y/N Company: _______________________________

Mother’s Maiden Name: __________________

U.S. Citizen Y N Green Card Y N

Second Adult:
First: ________________________Middle:___________________Last:____________________
DOB: __________________________________SS# ___________________________________
M / F/Transgender

Health Insurance Y/N Company: _______________________________

Mother’s Maiden Name: ___________________
Marital Status:
HOH:
Single __Married __Divorced __Widowed

U.S. Citizen Y N

Green Card Y N

2nd Adult
Single __Married __Divorced __Widowed

Does HOH receive SNAP and Cash Benefits? Yes No Cash Amt $______ SNAP $______
Do all Family Members Have Insurance Benefits at this time? Yes No Ins Co:________________
*** Please list all family members who will require assistance with Insurance benefits.
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________

Pregnancy:
Is anyone in the household pregnant: Yes / No
Who: _________________________________________Due Date: ________________________
Emergency Contact: ____________________________ Relationship: ______________________
Address: _______________________ Phone #: ______________________ Release: Yes No

H.O.U.S.E. PROGRAM
Family Member:
EA Six months:

Rapid Re-Housing Plan

Department of Housing and Community Development
Division of Housing Stabilization

Re-housing Plan (Section 1)
(for each family member 18 and older)

ay’s Date:
d of Household:
ividual:
mily Size:
lter Name:

Date Placed:
SSN (last 4 digits):

Contact Number:

Males:

Females:

Address:

Contact Number:

housing Case Manager:

Contact Number:

CD Homeless Coordinator:

TAO:

Contact Number:

A Case Manager:

TAO:

Contact Number:

our Re-housing Plan outlines specific activities intended to bring you closer to economic
lity and sustainable housing. Your goals, strengths and resources will be the basis for
loping a strategy to overcome homelessness as you, shelter staff and DHCD staff develops the
ousing plan.
hile you are in shelter, you will be expected to:
take part in activities leading to increased economic stability for 30 hours a week, such as:
job search or job training, and addressing any barriers to obtaining employment;
attend shelter meetings and workshops as a requirement of your re-housing plan;
meet with and cooperate with re-housing placement staff;
save 30% of your net income; and
accept an offer of housing unless you have good cause.
ur case manager and/or re-housing case manager will help connect you with appropriate
munity resources, including child care, transportation, medical and other supportive services,
eded.
1

H.O.U.S.E. PROGRAM

With the Re-Housing Plan, case management is
focused on helping families achieve a successful
housing placement and ongoing stabilization in order
to assist families develop the skills and resources
needed to sustain housing.

The area of focus in the Re-Housing Plan are:
1. Secure Housing
2. Economic Stability
3. Health and Safety
4. Children’s Stability

H.O.U.S.E. PROGRAM
Secure Housing
1. Explore all housing options
2. Collect necessary documentation
3. Address barriers: CORI, credit

issues, utility arrears, rental arrears
4. Devise strategy to increase income
5. Educational Attainment
6. Review & discuss housing offers

H.O.U.S.E. PROGRAM
 Economic Stability
1. Create a budget and repayment plan.
2. Work with DTA to enroll in ESP

programs and access child care and
transportation.
3. Save 30% of household’s net monthly
income and provide documentation.
4. Identify financial barriers and reduce
debt.
5. Attend financial education workshops.

H.O.U.S.E. PROGRAM
 Health & Safety
1. Attend required workshops
2. Access any services identified in the assessment process.
3. Schedule and keep all necessary medical appointments.
4. Weekly hours in all activities add up to 30 hours , unless

good cause is determined.

H.O.U.S.E. PROGRAM
Children’s Stability
 Register children for school,

access transportation and
ensure attendance.
1. Attend parent/teacher conf.
and other school functions.
2. Ensure well being of children
through after school
programs, recreation and
study time

TEST YOUR KNOWLEDGE: How much income must a family have in order to
afford market rent and avoid paying more than the recommended 30% of
their income towards rent in the state of Massachusetts?

EXPLORE ALL
HOUSING OPTIONS

REVIEW AND DISCUSS
HOUSING OFFERS

COLLECT NECESSARY
DOCUMENTATION

SECURE
HOUSING

STRATEGY TO
INCREASE INCOME

ADDRESS BARRIERS:
CORI ISSUES
CREDIT ISSUES
UTILITY ARREARS

Snapshot of the most Common
Barriers for Homeless Families.
:
•Poor Rental History, Evictions and Foreclosures
•Poor Credit History
•Cori Records
•Low Income
•No income
•Physical, Emotional and Mental Disabilities
•Poor Housing Resumes
•Utility arrearages
•No banking history
•Basic educational attainment
•Lack of work history
•English proficiency ability
•Immigration status
•Adequate child care arrangements
•Transportation
•Lack of safe, affordable housing (not enough
subsidized housing or vouchers available.

Intake Admission Data Form
HMIS DATA ENTRY ____________

HMIS EXIT ENTRY ___________________

Housing Specialist: ___________________

SS Location: _________________________________

Head of Household:
Entry Date: _____________DTA Office: ________________DTA Case Worker_______________
First: ________________________Middle:___________________Last:____________________
DOB: __________________ SS# ____________________ Phone #_______________________
M / F/Transgender

Health Insurance Y/N Company: _______________________________

Mother’s Maiden Name: __________________

U.S. Citizen Y N Green Card Y N

Second Adult:
First: ________________________Middle:___________________Last:____________________
DOB: __________________________________SS# ___________________________________
M / F/Transgender

Health Insurance Y/N Company: _______________________________

Mother’s Maiden Name: ___________________
Marital Status:
HOH:
Single __Married __Divorced __Widowed

U.S. Citizen Y N

Green Card Y N

2nd Adult
Single __Married __Divorced __Widowed

Does HOH receive SNAP and Cash Benefits? Yes No Cash Amt $______ SNAP $______
Do all Family Members Have Insurance Benefits at this time? Yes No Ins Co:________________
*** Please list all family members who will require assistance with Insurance benefits.
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________

Pregnancy:
Is anyone in the household pregnant: Yes / No
Who: _________________________________________Due Date: ________________________
Emergency Contact: ____________________________ Relationship: ______________________
Address: _______________________ Phone #: ______________________ Release: Yes No
Last updated on 02/6/2012

1

Child/Children Names:
1. ______________ _______________ ________________
First

Middle

2. ______________ _______________ ________________
First

Middle

Middle

Middle

Middle

Middle

F M DOB _____________ SS#

-

- -

.

F M DOB _____________ SS#

-

- -

.

F M DOB _____________ SS#

-

- -

.

F M DOB _____________ SS#

-

- -

.

F M DOB _____________ SS#

-

- -

.

Last

6. ______________ _______________ ________________
First

.

Last

5. ______________ _______________ ________________
First

- -

Last

4. ______________ _______________ ________________
First

-

Last

3. ______________ _______________ ________________
First

F M DOB _____________ SS#

Last

Last

Ethnicity:
HOH:
Hispanic _______
Secondary Adult:
Hispanic _______
Children: ____________ Hispanic _______
Children: ____________ Hispanic _______
Children: ____________ Hispanic _______
Children: ____________ Hispanic _______
Children: ____________ Hispanic _______

Non Hispanic ________
Non Hispanic ________
Non Hispanic ________
Non Hispanic ________
Non Hispanic ________
Non Hispanic ________
Non Hispanic ________

Race:
HOH:
_____White _____Asian _____Asian/White_____Multi-Racial _____American Indian/Alaskan Native
_____ Hawaiian/Other Pacific Island _____American Indian/Alaskan & White _____Black/African American /White
_____American Indian/Black ______Black/African American

Second Adult:
_____White _____Asian _____Asian/White_____Multi-Racial _____American Indian/Alaskan Native
_____ Hawaiian/Other Pacific Island _____American Indian/Alaskan & White _____Black/African American /White
_____American Indian/Black______Black/African American

Children:
_____White _____Asian _____Asian/White_____Multi-Racial _____American Indian/Alaskan Native
_____ Hawaiian/Other Pacific Island _____American Indian/Alaskan & White _____Black/African American /White
_____American Indian/Black______Black/African American

Reason for Homelessness:
_____Mental Health Disability

_____ Unemployment/Loss of Job
_____Military Discharge
_____Natural Disaster/Fire
_____Need for safety Animal

_____Discharge from Jail/Prison
_____Divorce/Break-up
_____Domestic Violence/Child Abuse
Last updated on 02/6/2012

2

_____Eviction for behavior or “Zero Tolerance” Drug Policy
_____Eviction- Expiring Use Building
_____Eviction –Landlord non-renewal, no fault
_____Family Conflict/Roommate Dispute
_____Financial-Rent Burden/Utilities Burden
_____Health Code/Safety Code Violations
_____Immigration from another Country
_____Immigration from U.S. City or State

_____Overcrowding
_____Over Housed
_____Physical Disability
_____Relocation
_____Substandard Housing
_____ Substance Abuse behaviors
_____Unable to pay utilities
_____Other:

Last Permanent Address: (Other than Hotel or Shelter)
City/Town with zip code
________________________________________________________________________________
Living Situation
_____Community Residence for Ex-Offenders
_____Emergency Shelter/Hotel with Voucher
_____Foster Care Home/Group Home
_____Living Outside/somewhere illegally
_____Hospital or Nursing Home
_____Hospital/Psych Facility
_____Hotel/Motel without Voucher
_____In the Military
_____Jail/Prison
_____Living/Staying with Family
_____Living/Staying with Friends
_____Mental Health Group Home

_____Owned by client No Housing Subsidy
_____Owned by client with Housing Subsidy
_____Perm. Housing for formally homeless (SHP,S+C,SRO)
_____Rented by client/no housing subsidy
_____Rented by client/Veterans Affairs
_____Rented by client/Non Veterans Affairs
_____Safe Haven
_____Student Housing
_____Substance Abuse/Detox Facility
_____Transit. Housing
_____Youth Residential Programs
_____Other Housing___________________

Length of Time at Living Situation
_____ Less than one week
_____More than one year
_____More than one week but less than a month _____Client does not know
_____One to three months
_____Client refused to say
_____Three months to less then one year

Education:
HOH:
_____Less than 9th grade
_____ Unknown

_____ Some High School _____ HS or GED _____ Post High School

Second Adult:
____Less than 9th grade
____ Unknown

_____ Some High School _____ HS or GED _____ Post High School

Employment/Programs:
HOH:
Employed Yes / No
Employed by: __________________________ Job Title: ______________________________
Programs enrolled in
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Second Adult:
Last updated on 02/6/2012
3

Employed Yes / No
Employed by: __________________________Job Title: ______________________________
Programs enrolled in:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Income: For “ALL” Family Members
Was income received in from any source in the past 30 days?
Family Member
_____No Income
_____Alimony/Spousal Support
__________/_________
_____Child Support
__________/_________
_____Earned employment Income __________/_________
_____Job Pension
__________/_________
_____Private Disability Insurance __________/_________
_____Public/General Assistance __________/_________
_____Rental Assistance
__________/_________
_____Retirement from Soc. Sec. __________/_________
_____Social Security Retirement __________/_________
_____SSDI
__________/_________
_____SSI
__________/_________
_____TANF/TAFDC/EAEDC
__________/_________
_____Unemployment Insurance _________/_________
_____Veterans Pension/Disability __________/_________
_____Worker’s Compensation
__________/_________
_____Other________________
__________/_________

Yes / No
Income Amount
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________

Were non-cash benefits received from any source in the past 30 days? Yes / No
Family Member
Amount (If applicable)
_____Food Stamps
__________/_________
_____Free Care
__________/_________
_____Healthy Start
__________/_________
_____Medicaid
__________/_________
_____Medicare
__________/_________
_____State Children’s Health Ins __________/_________
_____WIC
__________/_________
_____VA Medical Services
_________/_________
_____Private Disability Ins
__________/_________
_____TANF Child Care
__________/_________
_____TANF Transport Services __________/_________
_____TANF/Other Funded Services_________/_________
_____Pub Hsg/Sec 8/other rental assist__________/_________
_____Unemployment Insurance _________/_________

$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________

_____Veterans Benefits Medical
_____Vocational Rehab
_____Workforce Investment Act
_____Other insurance/benefit

$__________/$__________
$__________/$__________
$__________/$__________
$__________/$__________

Last updated on 02/6/2012

__________/_________
__________/__________
__________/__________
__________/__________
4

Special Conditions:
Condition

Affected HH Member/Condition

____None
____Alcohol Abuse 1
____Drug Abuse 1
____Developmental Disability
____Chronic Health Condition
____Domestic Violence
2
____HIV/AIDS
____Physical Disability
____Mental Health Problems 3

____________/____________
____________/____________
____________/____________
____________/____________
____________/____________
____________/____________
____________/____________
____________/____________
____________/____________

Receiving treatment or
Services for condition
_____No
_____Yes
_____No
_____Yes
_____No
_____Yes
_____No
_____Yes
_____N0
_____Yes
_____No
_____Yes
_____No
_____Yes
_____No
_____Yes
_____N0
_____Yes

1= If alcohol or drug abuse, is the abuse expected to last a long time and impair the person’s ability to live
independently?
_____No
_____Yes
2= If DV when did the last experience occur?
____Within the past three month’s
____Three to six months ago
____Six to twelve months
____More than one year
3= if mental illness, is it expected to last a long time and impair the person’s ability to live independently?
_____No
_____Yes
Shelter:
Have you been in a Family Shelter before? Yes / No Where was it located? ____________________________
If yes when did you enter____________ and when did you exit ______________.
Veteran Status:
Is the HOH a Veteran? Yes / No

Is the Second Adult a Veteran? Yes / No

Language:
What’s your Primary Language? ___________________ Would you like to enroll in ESL classes? Y N

Last updated on 02/6/2012

5

Head of Household:
Family Member:

Department of Housing and Community Development
Division of Housing Stabilization

Re-housing and Stabilization Plan
Part 2
Today’s Date:

(for each family member 18 and older)

_________

Date placed:

____________

Head of Household:
Individual:

SSN (last 4 digits):

Contact Number:

Family Size:

Males:

Females:

Home Address:

Unit:

Contact Number:

Stabilization Case Manager:

Shelter Program:

Contact Number:

DTA Case Manager

TAO:

Contact Number:

Your Stabilization Plan outlines specific activities and responsibilities intended to
bring you closer to economic stability and maintaining sustainable housing. Your
goals, strengths and resources will be the basis for developing a strategy to overcome
homelessness as you, stabilization staff and DHCD staff develops the Stabilization
Plan. You are encouraged to take on as much independent responsibility as you can
to maximize the benefits of your plan.
Your case manager and/or stabilization manager will help connect you with
appropriate community resources in your region, including child care, transportation,
medical and other supportive services, as needed. In addition to your own
stabilization obligations, your stabilization worker will:

Initiate primary contact with your landlord in person, by telephone, or letter and
follow up with your landlord at a minimum of every 3 months.

Obtain 6 and 12 month lease compliance verification letters from your landlord.

Contact you at least once a month in person (individually or in groups), by
telephone, or by letter in order to verify lease compliance, refer you to relevant
community services, and educate you about tenant rights and responsibilities.

Tailor stabilization services as necessary in response to your personal needs.

1

10/4/2012

Head of Household:
Family Member:

The following activities are part of your plan to maintain housing and move towards economic
and housing self-sufficiency. The assessment tool may be used to identify appropriate areas of
concentration. Your and your case manager will review your participation and completion of
these activities on a monthly basis.
Important: If a member of your family has a mental or physical disability that may prevent
you from doing an activity, we may be able to modify the activities in your plan to help you
participate successfully. Please request an ADA Accommodation.
Health Issue:  Yes  No if yes, please explain and verify_____________________________

Activities

Today’s Date: _____________

Activity Status
Progress
1. Lease Compliance and Ongoing Housing Search:

 Y N

Meet with or contact stabilization
_______________________
worker at least once a month regarding
lease status

Comments

___________________________________
___________________________________
___________________________________

Change addresses with housing authorities  Y  N
_______________________
and management companies
_____________________________
_________________________________
____________________________________


Track housing authority and management
company waitlists at least every 3 months

 Y N
_______________________
____________________________________
____________________________________
____________________________________


Address barriers to permanent housing
(ex.: CORIs, bad credit)

 Y N
_______________________
___________________________________
___________________________________
___________________________________

• Strengthen and update housing resume,
including landlord history and references

 Y N
______________________
____________________________________
____________________________________
____________________________________

2

10/4/2012

Head of Household:
Family Member:

Activity Status
Progress

Comments

2. Economic Stability and Development

Follow your budget and repayment plan
(Rental/utility arrearages, credit)
(See Attachment B)

 Y N
_______________________
____________________________________
____________________________________
____________________________________

Maximize and increase income through
benefits, employment and financial
education

 Y N
_______________________
___________________________________
____________________________________
____________________________________

Develop a plan for savings and accessing
basic banking programs

 Y N
_______________________
____________________________________
____________________________________
____________________________________

Continue education through GED & college  Y  N
_______________________
.
____________________________________
____________________________________
____________________________________

Participate in work training or professional  Y  N
_______________________
certification programs
__________________________________
____________________________________
____________________________________

Access DTA CIES program if TAFDC
recipient

 Y N
_______________________
____________________________________

(job placement assistance, childcare, transportation)

____________________________________

____________________________________

3. Health, Safety, and Well-Being

Register children for Head Start,
preschool, elementary and high school;
access transportation and ensure attendance

 Y N
______________________
___________________________________
___________________________________
___________________________________

Attend parent/teacher conferences and
other school functions

 Y N
______________________
___________________________________
___________________________________
___________________________________
3

10/4/2012

Head of Household:
Family Member:

Ensure well being of children through
after school programs, recreation and
study time

 Y N
______________________
___________________________________
___________________________________
___________________________________

Access any relevant services offered by
our community based private and public
partners

 Y N
______________________
___________________________________
___________________________________
___________________________________

Work with stabilization manager to
secure specialized services such as
mental health, substance abuse, or
domestic violence counseling

 Y N
______________________
___________________________________
___________________________________
___________________________________

Schedule and keep all necessary
appointments with stabilization worker
and other service providers

 Y N
______________________
___________________________________
___________________________________
___________________________________

Schedule next appointment with stabilization staff
to update stabilization plan
Date:

________ _______________

Additional notes:
__________________________________________________________________________

4

10/4/2012

Head of Household:
Family Member:

Stabilization Plan Agreement

I understand that the stabilization plan is a work in progress and that I am responsible for
completing the agreed upon activities and cooperating in the development of new activities.
I understand that consistently participating in and completing the stabilization plan activities
and remaining eligible for Emergency Assistance benefits pursuant to 106 C.M.R. ch. 309 are
requirements for continuing eligibility for temporary housing assistance.
I acknowledge that I have received a copy of the Flex Funds Case Review Policy and agree
that the Policy is incorporated into my Re-housing and Stabilization Plan and forms a part of
that Plan.
I agree to accept any modifications to my Re-housing and Stabilization Plan that are required
by DHS as part of any amendment to the DHS standard form Re-housing and Stabilization
Plan.
I understand that any extension of my Flex Funds subsidy at the end of my current Flex Funds
subsidy is subject to program and funding availability.
I understand that, if additional Flex Fund extensions are unavailable at the end of my current
Flex Funds subsidy, I will remain eligible for temporary emergency shelter benefits, provided
that I have been in substantial compliance with the stabilization plan and remain otherwise
eligible for Emergency Assistance.
I also understand that if I fail to cooperate with the stabilization plan, which is considered
housing assistance program services, and then lose the Flex Funds unit, I will be ineligible for
temporary emergency shelter benefits as specified in 106 CMR § 309.040 (B) (7).

_____________________________________________
Adult Household Member Signature

________________
Date

_____________________________________________
Stabilization Case Manager

________________
Date

Amendments
_______________________________________________________
_______________________________________________________
_______________________________________________________
5

________________
Date
Initial _________

10/4/2012

Head of Household:
Family Member:

6

10/4/2012

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