Iowa Homeless Information
Management System
ServicePoint
Release of Information
This agency participates in the Iowa Homeless Management Information Network. This network is administered by the Iowa
Institute for Community Alliances.
Because this Network is made up of many service providers across Iowa, you have the option to share part or all of your
information with other service providers from which you might be seeking services. This may reduce the time spent
answering basic questions regarding your situation, and allow that agency to focus on meeting your service needs.
The computer program used for this purpose has industry standard security protocols, and is updated regularly to meet these
security standards. The information you provide will only be shared with this agency, any other agency in the network you
designate, and limited staff of the Iowa Institute. No personally identifying information will be shared by our network with
any department the State of Iowa or the Federal Government. Information collected is housed in a secure server located at
Bowman Internet Systems in Shreveport, Louisiana. Limited staff persons of Bowman Systems have access to this server
and the data housed there and but only for network support and maintenance purposes. Data collected for the network will be
maintained for seven years from the date of entry and then any inactive record will be permanently deleted from the network.
The agency, from which you are currently receiving services, is the best resource to help you identify which other agencies
you may also benefit by receiving services. There is a list on the back of this form with participating providers by
community. You may select to have your information shared through the entire network, with only certain communities or
only specific agencies.
Please note; if you do not instruct this agency to release your information, no other service provision agency will have
access to it. If you do decide to share information at this time and later change your mind, you can revoke this
permission in writing at any time and security protections to prevent your information from being viewed by any
other service provider will be put into place.
My name and signature below indicates my permission to have my service information shared with the exception of
any item I indicate below with a check mark. This information will be shared as I have instructed on page two of this
form.
Remember: Please check the box next to any information that you do not want shared.
Please keep in mind that if you anticipate visiting another Network Provider, they will ask these same questions.
social security number
reasons for homelessness
birth date
disability / health
race
income type and amount
marital/family status
experience of domestic violence
gender
zip code of last permanent residence
veteran status
education info
homeless status
service transaction records
Client’s Printed Name_____________________________________________________
Shared by Iowa Statewide HMIS on HMIS.Info
Release of Information
Client’s Signature________________________________________________________Date________________
Participating Providers with the Iowa Homeless Information Management Network
I give my permission for this agency to share my approved information (with a check mark) with all agencies participating in the Iowa Homeless
Information Management Network.
I give my permission for this agency to share my approved information (with a check mark) with only the service agencies I have selected below.
Adel:
Ames:
Crisis Intervention & Advocacy Center
All Providers
A.C.C.E.S.S.
Emergency Residence Project
Youth and Shelter Services
Ankeny: RRACAP - Red Rock Area CAP
Atlantic: Family Crisis Support Network
Boone: Good Connections, Inc.
Burlington: All Providers
Burlington Area Homeless Shelter
Community Action of Southeast Iowa
YWCA of Burlington
Carroll: Domestic Abuse Prevention Center
Cedar Rapids: All Providers
ASAC - Area Substance Abuse Council
Catherine McAuley Center for Women
Foundation 2 Youth Shelter
HACAP - Inn Circle Project
MidAmerica Housing Partnership
Rapids AIDS Project
St. John of the Cross Catholic Worker House
The Safe Place Foundation
Waypoint Domestic Violence Services
Waypoint Services-Madge Phillips
Willis Dady Emergency Shelter
Cherokee: Council Against Domestic Abuse
Clinton: All Providers
Clinton Family YMCA
Information, Referral & Assistance Services
New Directions - Hightower Place
New Directions, Inc. - King House
Pathway Living Center, Inc.
Victory Center Rescue Mission
YWCA -Transitional Housing
Council Bluffs: All Providers
Family Housing Advisory Services, Inc.
Family Services
MICAH House Corporation
Phoenix House/Catholic Charities
The Christian Worship Center Creston: All Providers
MATURA Action Corporation
Rural Iowa Crisis Center
Davenport: All Providers
Family Resources, Inc.-Davenport
Humility of Mary Housing, Inc.
John Lewis Community Services
The Salvation Army Family Service Center
Valley Shelter Homes, Inc.
Vera French Housing Corporation
Decorah: All Providers
Helping Services of Northeast Iowa
NEICAC-Northeast Iowa CAC
Des Moines: All Providers
AIDS Project of Central Iowa
Anawim Housing
Beacon of Life, Inc.
Bethel Mission
Broadlawns Medical Center
CFI/Family Violence Center
Churches United Shelter
Creative Visions
Criminal Justice Ministries-Hansen House
Cross Ministries
Door of Faith Mission
Harbor of Hope
Shared by Iowa Statewide HMIS on HMIS.Info
Release of Information
Hawthorn Hill Ministries
HOME, Inc.
Homes of Oakridge
House of Mercy
Iowa Coalition for Housing and the Homeless
Iowa Homeless Youth Centers
Polk Co Dept of Community & Family Services
Proteus, Inc.
Rainbow Recovery Center, Inc./Bailey House
Riverfront-YMCA of Greater Des Moines
St. Ambrose Cathedral Housing Task Force
St. Joseph Emergency Family Shelter/Catholic Charities
The Home Connection
West Des Moines Human Services
Youth Emergency Services & Shelter
YWCA of Greater Des Moines
Dubuque: All Providers
Hillcrest Family Services
Opening Doors - Maria House
Project Concern
YWCA Domestic Violence Program
Fort Dodge: All Providers
Community and Family Resources (CFR)
D/SAOC-Domestic/Sexual Assault Outreach Center
Northwoods Living, Inc.
Upper Des Moines Opportunities-Safe Harbor
Youth Shelter Care (YSC) of North Central Iowa
YWCA-Fort Dodge
Graettinger: Upper Des Moines Opportunity, Inc.
Grundy Center: Seeds of Hope
Hiawatha: Hawkeye Area Community Action Program, Inc. (HACAP)
Indianola: RRACAP-Red Rock Area Community Action Program, Inc.
Iowa City: All Providers
DVIP-Domestic Violence Intervention Program
Four Oaks, Inc. of Iowa
Greater Iowa City Housing Fellowship
ICARE
Shelter House
Successful Living
Keokuk: Tri-State Coalition Against Domestic and Sexual Abuse
Knoxville: Turning Point
Marshalltown: All Providers
Domestic Violence Alternatives/Sexual Assault Center
House of Compassion
Mid-Iowa Comm. Action (MICA)
Mason City: All Providers
Crisis Intervention Service
Francis Lauer Youth Services
Northern Lights Homeless Shelter
Muscatine: All Providers
Family Resources, Inc-Muscatine
Muscatine Center for Social Action
Newton: Rainbow Recovery Center, Inc./New Beginnings
Oskaloosa: Crisis Intervention Services of Mahaska Co
Ottumwa: All Providers
Crisis Center & Women's Shelter
Rainbow Recovery Center, Inc./Amethyst House
SIEDA-Southern Iowa Economic Dev. Association
Remsen: Mid-Sioux Opportunity, Inc.
Shenandoah: Domestic Violence Education & Shelter
Sioux Center: Family Crisis Centers of Northwest Iowa
Sioux City: All Providers
Community Action Agency of Siouxland
Council on Sexual Assault & Domestic Violence
Crittenton Center - Emergency Youth & Project LIFE
Shesler Hall, Inc.
Siouxland Community Health Center
Siouxland Regional Transit
The Center of Siouxland
Spencer: Center Against Abuse & Sexual Assault (CAASA)
Spirit Lake: Discovery House
Waterloo: All Providers
Shared by Iowa Statewide HMIS on HMIS.Info
Release of Information
Christian Community Development
Family Service League-DV Shelter
Family Service League-Trans Housing
Jesse Cosby Neighborhood Center
Operation Threshold
The Salvation Army