Appendix P: Referral Form

OMB Control # 0970 – 0514

Expiration Date: 09/30/2021

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 mpergamit@urban.org.

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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 (SKIP TO PAST LIVING SITUATION SECTION)

☐ Transitional housing (SKIP TO PAST LIVING SITUATION SECTION)

☐ Hotel or motel paid for by charity or government agency (SKIP TO PAST LIVING SITUATION SECTION)

☐ Residential substance abuse treatment* (SKIP TO PAST LIVING SITUATION SECTION)

☐ Hospital (includes psychiatric hospitals) * (SKIP TO PAST LIVING SITUATION SECTION)

☐ Jail/incarcerated* (SKIP TO PAST LIVING SITUATION SECTION)

☐ 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)

Was the client homeless (in place not designed for sleeping accommodation/emergency shelter) prior to entering the institution)? ____________

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

Family is at risk of homelessness

Family will lose their primary nighttime residence within 14 days Y ☐ N ☐ U ☐

IF YES: No subsequent residence has been identified Y ☐ N ☐ U ☐

IF YES: family lacks resources/support to obtain other permanent housing. Y ☐ N ☐ U ☐

Family is fleeing or is attempting to flee domestic violence. Y ☐ N ☐ 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 defects which require considerable repair or rebuilding. Y ☐ N ☐ U ☐

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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 substandard housing

Housing unit does not have:

Operable indoor plumbing. Y ☐ N ☐ U ☐

A usable flush toilet inside the unit for the exclusive use of a family. Y ☐ N ☐ U ☐

A usable bathtub/shower inside the unit for the exclusive use of a family. Y ☐ N ☐ U ☐

Electricity, or has inadequate or unsafe electrical service. Y ☐ N ☐ U ☐

A safe or adequate source of heat. Y ☐ N ☐ U ☐

A kitchen. Y ☐ N ☐ U ☐

Housing unit has been declared unfit for habitation by an agency or government. Y ☐ N ☐ U ☐

Family is living in an overcrowded* unit (3 or more people per bedroom or

household head sharing a room with an adult that is not a significant other)

The family is living with its child(ren) in a unit that is overcrowded and this

overcrowding may result in the imminent placement of its child(ren) in

out-of-home care. Y ☐ N ☐ U ☐

Child(ren) not with family and if the family is re-united, the caregiver’s housing

unit would be overcrowded Y ☐ N ☐ U ☐

Family is living with a household member that could result in

placement of child or delay of discharge from placement. Y ☐ N ☐ U ☐

Family is living in a unit not accessible to disabled child(ren) 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 the family had 3 or more moves in past year? Y ☐ N ☐ U ☐

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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 ☐

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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]

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 housing authority? 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? Y ☐ N ☐ U ☐

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

Service Provision Plan

Who will be providing case management services for the family?

☐ Public Child Welfare Agency

☐ Public Housing Authority

☐ 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: ____________________

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