Form 1
Application and Serious Mental Illness (SMI) Verification
Applicant Information:
Print Name of Applicant (qualifying individual):
Gender:
M/F
Date of Birth:
Social Security Number:
Current Contact Address (if applicable):
Current Contact Phone Number (if applicable):
Message Phone:
Current E-mail Address (if applicable):
Applicant is:
Applicant has:
Homeless
Health Condition that warrants special accommodation
At-Risk of Homelessness
Wheelchair
Walker
Oxygen
Other:
**Verification below to be completed by the supportive services provider/case manager.
Verification of Serious Mental Illness or Severe Emotional Disturbance and DBH Program
Enrollment/Service Engagement: The applicant may provide records that document their eligibility OR they may
authorize DBH to contact a specific provider for verification. Documentation must include information that clearly states
the applicant meets the definition of serious mental illness (as defined in California Welfare and Institutions Code Section
5600.3 (b) (1)) or severe emotional disturbance (as defined in California Welfare and Institutions Code Section 5600.3 (a)
(1)) and the applicant is enrolled or engaged in services provided by DBH or one of its contracted mental health providers.
Name of Supportive Services Program/Agency:
Signature of Supportive Services Provider/Case Manager
Date Completed
MHSA – Office Use
Diagnosis verified by Behavioral Health-MHSA
Name:______________________________________
Approved
Denied
Date: ______________
Form 2
Certification of Homelessness
Instructions:
Please provide certification which will verify and document your knowledge of an applicant being either…
 Continuously homeless for the past year – “Section A” to be completed by Facility/Shelter/Program.
 Having had at least 4 episodes of homelessness within the past 3 years of at least 15 days of homelessness per episode.
- “Section B” must have written certification on Letterhead from Facility/Shelter/Program/and/or Case Manager for
each episode.
Section A - Certification – Continuously Homeless for the past year
I certify that
has been continuously homeless for the past year and living on the
(Applicant’s Name)
streets and/or staying at an emergency shelter
during the past year.
(Facility/Shelter/Program)
Additional detail of the client being continually homeless for the past year (or longer) may be provided here.
This Agency / Service Provider are classified as one of the following types of facilities / programs:

Emergency Shelter
Other: ______________
Name of Agency
Signature of Agency Staff
Tittle
Phone
Date
Section B - Certification – Four (4) Episodes of Homelessness within the past three (3) years
I certify that __________________________ stayed at the following locations and/or on the streets for the following periods of time:
(Applicant’s Name)
Example: Lifeline Shelter, Cleveland Between: 1/12/10 and 8/15/10
Live At:
(Facility-Shelter/Program/Streets)
Start Date
End Date
Check when
Supporting Letter is attached.
1)
2)
3)
4)
Additional detail of the applicant’s episodes of homelessness may be provided here.
Before coming to this Facility/Shelter/Program, the homeless person resided at___________________________________.
I
certify that I have met with my worker and that all of the above information is correct.
(Applicant Name)
Signature of Applicant: ________________________________
Signature of Mental Health Staff/Case Manager
Title
Date: ___________________
(
)
Phone
Date
Form 3
Certification of At Risk of Homelessness
Instructions:
Please provide certification which will verify and document your knowledge of this applicant who due to housing instability,
is at imminent risk of homelessness.
 Certification - “Section A” completed by Supportive Services/Agency.
 Self-Statement – “Section B” completed by Applicant.
Section A - Certification – At Risk of Homelessness
I certify that
due to housing instability, is at imminent risk of homelessness.
(Applicant’s Name)
Current living situation:
How long did applicant stay at that place? _________________.
Additional details of applicant’s living situation may be provided here.
This Agency / Service Provider are classified as one of the following types of facilities / programs:
Emergency Shelter
Mental Health Institution
Transitional Housing
Name of Agency
Correctional Facility
Permanent Housing
Substance Abuse Facility
Signature of Agency Staff
Medical Institution
Other: ______________
Tittle
Phone
Date
Section B - Applicant – Self-Statement of Homelessness / At Risk of Homelessness
Prior history of housing within past year (check all that apply):
Living in/ with
Domestic Violence Situation
Friends
Emergency Shelter
Hospital
Exiting Child Welfare
Hotel/Motel
Exiting Juvenile Justice System
Local Jail
Family
Residential
Streets
Treatment Facility
Other:
What else would you like to share about your history? For example, “I can not remember the name of the place where I was living
during the fall of 2011 but I believe that it was a homeless emergency shelter. I have problems with my memory from that time due to
an illness.”
I certify that I am, or was homeless, or at risk of homelessness as identified above.
Signature of Applicant: ________________________________
Date: ___________________
MHSA – Office Use
At-Risk of Homelessness verified by Behavioral Health-MHSA
Approved
Referred for Imminent Risk of Homelessness Review
Name:______________________________________
Reviewed for Imminent Risk of Homelessness
Denied
Date: ______________
Approved
____________________________, Karen Markland, MHSA - Division Manager
Denied
Date: _____________