Shared Housing Services

SHS Shared Housing Services Shared Housing Services provides affordable, alternative housing solutions to continue and enhance the independence and self-sufficiency of individuals and families To complete the application process, copies of your photo ID, and social security card are required. Please bring them to our office or fax/mail them with your application. A background check is also required for which there is a $20.00 fee. HOMESEEKER APPLICATION : Office Use Only: HMIS Client ID: Have you ever applied with Shared Housing before? When? Name (Last) (First) (Middle Name) Address_ (Street) (City) (Zip) Maiden or Other Names Used Are you a veteran? Yes No City of Tacoma Pierce County Out of Area How did you find out about Shared Housing Services? Social Security # ID/ License # Age of Birth Race Ethnicity Hispanic: Yes No Have you been through Access Point? Marital Status: Single Married Widowed Separated Divorced Single Parent Phone (C) (H) Best time to call Email Are you homeless? Are you in a shelter? If yes, which shelter? How long have you been homeless? How many times have you been homeless? Literally homeless (Losing housing in 0-7 days)? Imminently losing your housing (Losing housing in 7-14 days)? Unstably housed and at-risk of losing their housing? Stably housed? Have you experienced domestic violence? If yes when: Within past 90 days? 3-6 months ago? 6-12 months ago? 1+ years ago? Refuse to answer? Are you disabled? If yes, is it a long term disability? Start date: Disability Type (s): Are you receiving services for your disability? If yes, what services? Are you receiving benefits? If yes, What? Start date: Medications? NAMES IN HOUSEHOLD RACE GENDER AGE BIRTHDATE SS# 1

Of the children listed above, who is currently attending school? WORKING BUDGET CURRENT INCOME BEING RECEIVED EXPENSES FOR THE LAST MONTH SOURCE OF INCOME DSHS (TANF, GAX, etc.) Food Stamps Unemployment Child Support SSI / SSA / SSD Wages / Salaries Investments / Savings / Annuity Retirement / Pensions Rents Other: TOTAL LIVING EXPENSES Rent / Mortgage Ins Taxes Utilities Food Auto / Ins /Payment / Gas Bus Pass Child Care Entertainment - Cable Home Phone / Cell Phone Healthcare Insurance Clothing, Personal Care Items Credit Cards Other: TOTAL Budget Comments: Employment Occupation Present or most recent employer Length of employment Student Highest Level of Education Completed Year in School Estimated Graduation What is your health condition compared to people your age? Excellent Very Good Good Fair Poor Have you lived in any other state in the last 10 years? Yes No If yes please list the state(s) and for how long: Have you been evicted? If yes, how many times? Have you shared housing before (non-family)? Yes No Was it successful? Is this move urgent? Match needed by: Have you been involved with CPS? Have you ever been detained, arrested, or convicted of a crime? Yes No Do you have active warrants? Yes No If Yes, please explain: When? Is anyone forcing you to work in a profession against your will or taking money you rightfully earned? Yes No PLEASE CIRCLE AT LEAST 3 GOALS YOU WANT TO ACHIEVE TO BECOME MORE SELF SUFFICIENT AND/OR GAIN A BETTER QUALITY OF LIFE THROUGH HOMESHARING 1. To obtain affordable housing 2. Be within walking distance to work/school or bus stop 3. To improve quality of living situation 4. Maintain stable housing 5. Able to meet monthly housing cost 6. Facilities to maintain personal hygiene and laundry 7. To better meet nutritional needs 8. Safe/Secure housing 9. A place to study/do homework to further education 10. To overcome homelessness 11. To obtain independent housing and not rely on relatives or friends 12. To help someone 13. To increase Income 14. Companionship 15. Receive services 16. Provide services for free room and board and/or income 17. Other Please Specify: 2

Please List the 3 Top Locations you Desire to Live: 1. 2. 3. PLEASE FILL OUT BOTH COLUMNS Fill this column out to describe yourself y/n Fill this column out to discuss preferences: Are you okay living. Are you male? With a male? Are you female? With a female? Are you a couple? With a couple? # Of children With children? Total number of people? How many people total? Do you smoke? In a home with smoking? Do you drink? In a home with drinking? Do you have pets? In a home with pets? Do you have furniture? In a furnished bedroom? Do you have storage? Any special requirements? Do you need storage space? Other: y/n Comments Maximum Rent? Current Rent? Are you interested in exchanging services for: Reduced rent Free rent Free room and board Room, board and compensation if yes, what amount $ Are you willing to provide any of these services? Housework Cooking Errands Handy Man Driving Gardening Laundry Other Caregiving? Yes No Experience? Any past drug use? Yes No Last used? Treatment Where What Kind of person would you be compatible with? (personality traits, daily routines, cleanliness standards, etc.) What irritates you about people? Do you have some traits that might irritate a home sharer? What would someone like about you? Emergency Contact? Relationship Phone Constraints in daily living? Yes No If yes, describe: How do you deal with them? Can you manage stairs: Yes No How many rooms do you need? Which Floor? Do you need to be near public transportation? Do you drive? Own your car? Do you need parking space? How long do you want this arrangement to last? If you find a housemate through other efforts will you notify us? Any concerns and/or questions about homesharing? 3

Criminal History Policy As a social service agency, we value the safety and well-being of our clients, employees, and volunteers. It is therefore the policy of Shared Housing Services (SHS) to carefully screen all applicants for any criminal charges, arrests, convictions, and warrants. Applicants are screened through Sound Screening s multistate background check and the Washington State Patrol. Based on the information received by SHS through a completed background check, it is our policy not to refer any applicant to the Adult Home Sharing Program who has been charged, arrested, or convicted of the following crimes within the last ten years: felonies, thefts, domestic violence, crimes of child or elder abuse, and any actions involving destruction of property or physical violence toward persons. Additionally, any active warrants will also serve as grounds for denial of participation from the program, regardless of how old the warrant is. Applicants must resolve all active warrants and go through the appeal process in order to be reconsidered for participation. Clients who possess a criminal history that features sexual crimes, murders, or voluntary manslaughter within their lifetime will be automatically disqualified and unable to request an appeal. Upon receipt of an adverse criminal history report, the applicant will be sent a letter denying their application due to relevant criminal history. It will state which crimes fall under the policy criteria as well as procedures to follow if the client wishes to seek review/reconsideration through the appeal process. The client is allowed a period of three months to schedule a criminal appeal appointment. If the client fails to do so within this given time frame, they will not be able to reapply for entrance into the program for the next three years. Policy on nondiscrimination: All services offered by shared housing services are provided in a manner which is free from discrimination on the basis of race, color, religion, sex, sexual orientation (gender identity/expression), national origin, age, handicap, and familial status. I certify that I have read the Criminal History Policy and that I understand and agree to the above information. Participant Signature Spouse/Partner Signature Shared Housing Services Release of Information (general) I,, hereby authorize the Shared Housing Services (SHS) staff to send information to and discuss my personal circumstances with Shared Housing Services coordinators and staff of other agencies. It is understood that any interchange of information made between staff and coordinators of SHS and other agencies will be used only for purposes of attempting to determine appropriate services on my and my family s behalf. I also hereby authorize Shared Housing Services Staff to provide information supplied by myself to potential home sharers in the process of attempting to bring about a home sharing arrangement for me and information on any arrest and /or criminal convictions obtained by Shared Housing Services. 4

Participant Signature Spouse/Partner Signature Shared Housing Services may speak to the following people, on my behalf: AGREEMENT OF NON-LIABILITY I understand that the staff of Shared Housing Services will use their facilities to bring together those who have available housing (homeowners) with those who express a desire for housing (home seekers). I, as a homeowner/home seeker, understand that Shared Housing Services is not the agent of either party, but acts only as a facilitator, to provide the opportunity for the parties involved to come together and work out an acceptable housing agreement. I, as a homeowner, am not relying entirely on Shared Housing Services to screen home seekers. All credit checks, references and all other background information will be obtained and/or confirmed by myself. I, as a home seeker, am not relying entirely on Shared Housing Services as to the homeowner s background or as to condition of the premises and their suitability for my needs. I agree to obtain and/or confirm information myself. Any disputes between the homeowner and home seeker which may arise shall not involve the staff of Shared Housing Services, either individually or as a group, and I will not hold staff responsible for any claims, damages or other consequences which may arise from any home sharing arrangement. I have also been advised to seek the services of an attorney should I have any questions about my legal rights and the laws of the State of Washington. I have read and understand the above statement. Participant Signature Spouse/Partner Signature 5

Program Exit Guidelines Shared Housing Services (SHS) is a non-discriminatory, equal opportunity non-profit, shared housing agency. We strive to serve Tacoma, larger Pierce County, and South King County, regardless of age, race, religion, sexual preference, or socio-economic status. As part of the program, SHS requires everyone to provide copies of identification, Social Security cards, and proof of income. In addition to this, all applicants for Shared Housing Services are required to pay a $20 criminal background fee and pass a criminal background check based on the agency s criminal history policy. If a person is having trouble meeting any of these requirements, he or she should talk with staff to discuss alternatives. Below is a list of reasons a participant may no longer receive services and be exited from the program: o Falsifying information o Disrespectful to staff in person, on the phone, or in writing o Disrespectful behavior towards another home sharer or home provider o Damage done to SHS property, the property of a home provider, or the property of a home seeker o Inappropriate behavior or boundaries towards staff or a program participant o Crimes or illegal activity committed while in the program o Non-compliance with substance abuse or mental health treatment o Unable to contact a non-matched program participant by phone, email, and mail after 3 months of trying o Failure to comply with services or rent contractually agreed upon by the home seeker and home provider o If the home becomes uninhabitable or not fit for home sharing Staff exercises their right to exit anyone from the program if they fall into one of the above categories. This list is not comprehensive and someone may be asked to leave for another reason. In addition, staff may use discretion at any time and allow a participant to stay in the program based on the nature of the offense. I,, have read and understand the above guidelines. I acknowledge that anything listed above may result in my dismissal from the program, and that I am responsible for my own behavior towards staff, volunteers, and program participants. Participant: : Spouse/Partner: : SHS Staff: : 6

PHOTO/VIDEO/AUDIO MEDIA RELEASE FORM By signing this release, I give Shared Housing Services permission to use (1) my picture including photos, videos, and electronic images, and (2) my voice including sound and video recordings. This gives Shared Housing Services employees and partners permission to publish, reproduce, and distribute my name, image, and voice in all languages, media, formats and markets now known or created in the future, including, but not limited to: Conferences and fundraising events, inclusion in newsletters, press releases, blogs, social media, donation requests, news coverage, advertising via television and internet, and website content. I agree to hold harmless Shared Housing Services and its staff and partners for any alternation of my image or voice, intentional or unintentional, which may arise in the production process. I waive the right to receive payment for Shared Housing Services use of any of the material described above, and to inspect or approve finished photos, audio, or video. I am 18 years of age or older, have read this release and understand its contents. IN WITNESS WHEREOF, I have executed this release on (date). Name 1 (please print) Name 2 (please print) Signature Signature MINORS: I certify that I am the legal parent or guardian of the following minor(s), under the age of eighteen, to whom this release shall apply. Parent / Guardian Name (please print) Name (Minor 1) Name (Minor 2) Signature Age Age [ ] CLIENT(S) DECLINED PHOTO RELEASE* Witness (Please Print) Witness Signature *Declining this release has no effect on distribution of services. 7