SHELTER PLUS CARE
REFERRAL/APPLICATION PACKET
Applicant’s Name: _________________________________________________
Date: ____________________________________________________________
Referral Source: ___________________________________________________
Received Date: ____________________________________________________
Staff: ____________________________________________________________
Fairview Recovery Services helps people with the disease of alcoholism, chemical
dependency, and co-occurring conditions live independent, healthy, and productive lives by
providing a continuum of individualized services and care.
Updated August 2016
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SHELTER PLUS CARE
REFERRAL/ADMISSION PACKET
TABLE OF CONTENTS
Cover Sheet Page 1
Table of Contents Page 2
Introduction Page 3
2-Way Consent for Release: Continuity of Care (2 copies) Page 4-5
Application Page 6-7
Letter Documentation of Homelessness Page 8
Certification of Homelessness Page 9
Client Questionnaire Page 10
Medication Policy Page 11
Overnight Visitor Policy Page 12
Relapse Policy Page 13
Vocational/Educational Policy Page 14
Resident Admission Agreement Page 15-17
Release-LOCADTR TRS 62 Page 18
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Introduction
Thank you for your interest in Fairview Recovery Services' Shelter Plus Care Program. The
Shelter Plus Care Program is a HUD funded subsidized housing program that assists
homeless people with disabilities. In order to participate in the Shelter Plus Care Program,
the client must meet the HUD definition of homelessness, have a disability documented by a
qualified health professional and participate in supportive services that are equal to or greater
in value to the yearly costs of the rental subsidy they receive. The overall goals of the Shelter
Plus Care Program are: 1) to increase housing stability; 2) to increase skills and/or income;
and 3) to gain greater self-sufficiency.
In order to expedite your application please complete and provide the following:
1. Shelter Plus Care Application Form
2. Shelter Plus Care Resident Agreement
3. Shelter Plus Care Medication Policy
4. Shelter Plus Care Vocational Policy
5. Shelter Plus Care Overnight Visitor Policy
6. Current Psychosocial Evaluation
7. Provide Documentation of Homelessness
8. Copy of Birth Certificate
9. Copy of Social Security Card
10. Consent for Release of Information
After we receive the items listed above, your client will be scheduled with an interview with
the Shelter Plus Care Case Manager to determine eligibility.
If you have questions, please contact the Shelter Plus Care Case Manager at (607) 722-8987
extension 240.
Again, thank you for interest in Fairview Recovery Services.
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FAIRVIEW RECOVERY SERVICES, INC.
Fairview and Merrick Community Residences
Supportive Living
Addictions Crisis Center
5 Merrick Street, Binghamton, NY 13904
Consent for Release of Information Concerning Alcoholism/Drug Abuse Patient
Instructions: Prepare one (1) copy for patient’s case record. If this form is used for billing purposes, prepare additional copy
for Patient Resources Office. If this form is sent to another agency for information, prepare a second copy for patient’s case
record.
Patient Name: _______________________________________________________________________________
Last First MI
DISCLOSURE WITH PATIENT’S CONSENT
Extent or nature of information to be disclosed:
_____________________________________________________________________________________
Purpose or need for the disclosure: Continuity of Care
_____________________________________________________________________________________
_____________________________________________________________________________________
Between name of person or organization disclosing information:
_____________________________________________________________________________________
And name of the person or organization to which the disclosure is being made: ____________________
___Fairview Recovery Services, Inc.____________________________________________________
I, the undersigned, have read the above and authorized the staff of the disclosing facility name to disclose such information as
herein contained. I understand that this consent may be withdrawn by me at any time except to the extent that action has
been taken in reliance upon it. This consent shall expire 6 months from its signing, unless a different time period, event or
condition is specified below, in which case such time period, event or condition shall apply. I also understand that any
disclosure is bound by Title 42 of the Code of Regulations governing the confidentiality of alcohol and drug abuse patient
records and that re-disclosure of this information is forbidden without written authorization on my part.
Time period, event or condition replacing period specified above:
6 months following date of discharge
Note: Any information released through this form will be accompanied by Form A-4400 Prohibition on Re-disclosure of
Information Concerning Alcoholism/Drug Abuse Patient.
________________________________________ __________ ________________________________________ __________
Patient Signature Date Signature of Parent/Guardian when required Date
________________________________________ __________ ________________________________________ __________
Patient Name (Printed) Date Parent/Guardian Name (Printed) Date
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FAIRVIEW RECOVERY SERVICES, INC.
Fairview and Merrick Community Residences
Supportive Living
Addictions Crisis Center
5 Merrick Street, Binghamton, NY 13904
Consent for Release of Information Concerning Alcoholism/Drug Abuse Patient
Instructions: Prepare one (1) copy for patient’s case record. If this form is used for billing purposes, prepare additional copy
for Patient Resources Office. If this form is sent to another agency for information, prepare a second copy for patient’s case
record.
Patient Name: _______________________________________________________________________________
Last First MI
DISCLOSURE WITH PATIENT’S CONSENT
Extent or nature of information to be disclosed:
_____________________________________________________________________________________
Purpose or need for the disclosure: Continuity of Care
_____________________________________________________________________________________
_____________________________________________________________________________________
Between name of person or organization disclosing information:
_____________________________________________________________________________________
And name of the person or organization to which the disclosure is being made: ____________________
___Fairview Recovery Services, Inc.____________________________________________________
I, the undersigned, have read the above and authorized the staff of the disclosing facility name to disclose such information as
herein contained. I understand that this consent may be withdrawn by me at any time except to the extent that action has
been taken in reliance upon it. This consent shall expire 6 months from its signing, unless a different time period, event or
condition is specified below, in which case such time period, event or condition shall apply. I also understand that any
disclosure is bound by Title 42 of the Code of Regulations governing the confidentiality of alcohol and drug abuse patient
records and that re-disclosure of this information is forbidden without written authorization on my part.
Time period, event or condition replacing period specified above:
6 months following date of discharge
Note: Any information released through this form will be accompanied by Form A-4400 Prohibition on Re-disclosure of
Information Concerning Alcoholism/Drug Abuse Patient.
________________________________________ __________ ________________________________________ __________
Patient Signature Date Signature of Parent/Guardian when required Date
________________________________________ __________ ________________________________________ __________
Patient Name (Printed) Date Parent/Guardian Name (Printed) Date
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Date:_________________
APPLICATION
Shelter Plus Care Program (S+C)
I. APPLICANT INFORMATION
Please check the size of the unit you are applying for:
Efficiency 1Bedroom 2 Bedroom 3 Bedroom
Name
______________________________________________________________________________________
Address City State Zip
______________________________________________________________________________________
Phone Number How long have you lived at this address?
______________________________________________________________________________________
Type of Housing currently living in (emergency or transitional housing, with friends, own apartment, etc
Are you presently involved in outpatient treatment?: yes no If yes, which type of treatment?
Outpatient Drug and/or Alcohol: Where:______________________ Frequency:_________________
Outpatient Mental Health: Where:______________________ Frequency:_________________
II. HOUSEHOLD COMPOSITION
List the Head of Household and all other members who will be living in the unit. Give the relation of each
member to the head
Participant Name Relationship
to Head of
Household
Birth Date Age Sex Social Security #
Do you expect a change in your household composition? Yes No
If yes, please explain:
______________________________________________________________________________________
Please explain any special housing needs you would need:
______________________________________________________________________________________
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Are you or anyone in your household subject to state lifetime registration requirement for sex offenders?
yes no If yes, identify household member
______________________________________________________________________________________
Have you or anyone in your household ever been convicted of a crime?
yes no If yes, identify household member
______________________________________________________________________________________
III. HOUSING HISTORY
Have you ever been evicted? yes no If yes, please explain reason(s)::
______________________________________________________________________________________
How many times have you been homeless in the last four years?
______________________________________________________________________________________
IV. FINANCIAL INFORMATION
Present Source of Income Monthly Amount
______________________________________________________________________________________
Health Insurance: Food Stamps: yes no
Medicaid None Amount:
Medicare Other (specify):
______________________________________________________________________________________
Have you contacted NYSEG within the past 30 days, about potentially setting up services? yes no
Who did you speak with at NYSEG? ________________________________________________________
Do you owe any utility balances? yes no
If yes, how much is your back balance: ______________________________________________________
What is your plan for repayment? __________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
V. APPLICANT CERTIFICATION
I/we certify that if selected to receive assistance, the unit I/we occupy will be my/our only residence.
I/we underst
and that the above information is being collected to determine my/our eligibility. I/we
certify that the statements made in this application are true and complete to the best of my/our
knowledge and belief.
______________________________ ___________________
Signature of Applicant Date
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CLIENT HOMELESS STATUS: ELIGIBILITY DOCUMENTATION
Client Name: _____________________ Date of Intake: ______________
Check the current status and attach the appropriate documentation to verify homelessness eligibility.
Homeless Status Type of Documentation Documentation
Attached
Living on the street A signed and dated general certification from an outreach
worker verifying that the services are going to homeless
persons, and indicates where the persons served reside.
Persons living on the street
Persons coming from living
on the street (and into a
place meant for human
habitation)
Staff should provide written information obtained from third
party regarding the participant’s whereabouts, and, then sign
and date the statement.
Persons coming from an emergency
Shelter for homeless persons Written referral from the agency.
Persons coming from
transitional housing for
homeless persons
Written verifications to include residency and
homeless status prior to program entry.
Persons being evicted from
a private dwelling
Documentation of income, efforts to obtain housing, why
participant would be on street, and either documentation of
formal eviction proceedings or statement from family
evicting participant. (not eligible for acceptance directly into PH
from 2005 awards onward.)
Persons from a short-term stay
in an institution who previously resided
on the street or in an emergency shelter
Written verification from the institution’s staff that the
participant has been residing in the institution for less than
31 days, and information on the previous living situation.
Persons being discharged
from a longer stay in an
institution
Written verification from the institution of discharge within
one week of accepting client into SHP/S+C program AND
documentation of income, efforts to obtain housing, and
why person would be homeless without assistance.
Persons fleeing domestic
violence
Written, signed and dated verification from the participant.
Other: Written verification from client or referring agency.
CHRONIC HOMELESSNESS
Single, disabled Adult +
Continuously homeless for 1 yr or more
OR.. 4 episodes of homelessness in
the past 3 yrs (streets/shelters)
Written verification from outreach workers, shelters
AND brief, written statement regarding previous shelter/street
stays (dates, locations)
AND – documentation of disability
NOTES:
STAFF MEMBER: ______________________________________________ Date: ________________
CLIENT: I verify this information is true & accurate. I confirm that I have been or am about to be homeless.
_____________________________________________________________ Date: ________________
Signature of Client
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SHELTERPLUSCAREQUESTIONNAIRE
CLIENTNAME:________________________________
DATE:________________________________
TOBEF
ILLEDOUTBYAPPLICANT
WhatdoyouwishtoaccomplishwhileintheShelterPlusCareProgram?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Whatisyourprimarysourceofincome?_____DSS _____SSI/SSD_____OTHER_____NONE
Whichsupportservicesareyoucurrentlyinvolvedin?
___CaseManagement
___IntensiveDayTreatment
___Alcohol/SubstanceAbuseServic
es
___MentalHealthServices
__
_HealthCare
___P
robation/Parole
___Ed
ucation
___Other:(Ex
plain)
___________________
__________________________________________________________________________
_____________________________________________________________________________________________
Doyouowepastutilitybills?_____Yes_____No
Haveyoueverbeenevictedfromanapartment?_____Yes_____No
Ifso,whowasthelandlord?____________________
_______________________________________________
I understand that, in order to participate in the Shelter Plus Care Program, I must participate in
supportive services that are equal to, or greater in value, to the yearly costs of the rental subsidy I
receive.IamawarethattheoverallgoalsoftheShelterPlusCareProgramare:1)toincreasehousing
stability;2)toincreaseskillsand/orincome;and3)togaingreaterself‐sufficiency.
_______________________________________
Signature
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Medication Policy
On admission to Shelter Plus Care Residents will review the medications that have been
prescribed to them with their case manager. Residents must demonstrate they ability to manage
their own medications before admission.
Residents must inform staff when any of the following occurs:
1. Changes in Prescriptions
2. Beginning a new medication
3. Experiencing adverse reactions or side effects to medications
4. Questions regarding medications
I agree to take my medication as prescribed by the doctor, and agree not to abuse my
medication.
Resident’s Signature _______________________ Date ______________
Counselor’s Signature ______________________ Date _____________
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Overnight Visitor Policy
1. I understand that I may use my discretion in allowing when I invite an
overnight guest(s).
2. I agree that all guests will be alcohol and/o drug free.
3. I agree to assume full responsibility for my children.
4. I agree that Fairview Employees or clients are not to be responsible
for my children at any time.
5. I understand that guests determined by Fairview staff to be
inappropriate will not be allowed in my residence.
6. I agree that there will not be guests in my residence when I am not at
home (except with prior FRS staff approval)
7. I agree that no one but me will have keys to my residence.
__________________________________ ____________________
Client Signature Date
__________________________________ ____________________
FRS Staff Signature Date
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Shelter Plus Care
Relapse Policy
1. We will treat all clients’ relapses on an individualized basis.
2. Upon notification of relapse, I understand a meeting will be held with my primary S+C
case manager. This will be for the purpose of gathering facts and information regarding
the events leading to the relapse.
3. The next step will include a team meeting, which will include all providers involved with
my care. I understand, I will be given an opportunity to present the team with any
information I feel is important in the decision making of my continued care and recovery.
4. The team will make a recommendation based on the individual needs of the client and
present it to the client.
5. Following presentation to the client the service plan will be amended to reflect new
treatment plan.
Client signature_____________________________ Date ______________________
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SHELTER PLUS CARE VOCATIONAL POLICY
As a participant of the Shelter Plus Care Program, I agree to the following Voc/Ed policy:
1) I agree upon admission to met with a Career Choices Unlimited case-manager to do:
a) create and or update Vocational Educational plan.
b) inform of residency changes.
2) I agree to be a participant in one of the following: Employment, volunteer work,
GED classes, or college.
3) I agree to follow through with all goals agreed upon with the CCU case-manager until
completion of the Voc/ED program.
Residents Signature ____________________________ Date: _____________________
Counselor’s Signature___________________________Date:______________________
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Fairview Recovery Services, Inc.
Resident Contract
Shelter Plus Care Program
Fairview Recovery Services, Inc. is a private, nonprofit agency with the mission to improve the
quality of life and health of persons diagnosed with and recovering from alcoholism, substance abuse and
other disabling conditions. Providing you with residential, rehabilitation and support services pursues this
goal. The purpose of this contract is to outline what is expected of you and the role of staff to ensure
that you have a safe, secure supportive setting in which to live and to work on your rehabilitation goals.
Client Expectations: As a resident of Fairview Recovery Services, Inc. Community
residence, I agree:
1. To treat all community members (other residence and staff) with dignity, and to respect their
personal rights and property, their right to privacy and their right to receive support as a member of
Fairview Recovery Services, Inc. community.
2. To participate in the development and carrying out of the activities of my individualized rehabilitation
program to include:
• Maintain sobriety and abstinence from non-prescribed drugs.
• Meeting with Fairview Recovery Services, Inc. staff on a regularly scheduled 1:1 monthly
basis to discuss my plan, services, progress, and changes in my plan, and any other concerns
that need to be shared.
• Being involved in a program of goal-oriented activities, therapy, rehabilitation, work and/ or
training, for at least 20 hours a week.
Maintaining regular contact with my primary therapist/ counselor.
3. To assume responsibility for my health and hygiene and for the care and safe keeping of Fairview
Recovery Services, Inc. property, personal property, and personal living areas to include:
• Keeping myself in good health and maintaining good personal hygiene.
• Maintenance and cleaning of the apartments.
• Assuming responsibility of apartment keys by
insuring against loaning or duplication, and
promptly returning all issued keys upon request.
• Assuming financial responsibility for lost or damaged Fairview Recovery Services, Inc.
property at replacement value to be established by the Clinical Director.
4. To give 30 days written notice of my intent to leave Fairview Recovery Services, Inc.
5. To insure my physical and emotional well-being and that of the community member
• Supporting fire prevention activities by using smoking materials (candles, incense etc.) only
in designated areas and in a safe responsible way.
• Learning the fire evacuation plan and participating in fire drills.
• Refraining from the storage and use of weapons in or around the apartment.
•
As a client with a history of alcohol or other substance abuse or dependence, complete
abstinence from all non-prescribed, mood-altering substances is expected in accordance with
my individualized rehabilitation plan. I further understand that any use will result in an
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evaluation by staff to determine what care and attention is needed to insure my health and
safety and to decide about my continued participation in the program.
• Informing staff of all prescribed and over-the-counter medications I am taking and
immediately reporting changes in dose and frequency, and then taking these medications
only as approved by my physician.
• Preparing and storing food in a responsible way that insures my safety and that of others, as
well as Fairview Recovery Services, Inc. property and to consume food and beverages only in
designated areas to insure a clean environment.
• Informing staff when I will be away from my apartment for longer than two days at a time.
• Welcoming guests within the following guidelines: children need to be carefully supervised
during their visit;
occasional
overnight visitation is permitted All guests must be clean and
sober.
• Agreeing that the staff may enter my apartment without my prior permission to make routine
maintenance checks and at any other time, there is a concern for any health or safety issue
or when there is a concern that I am not complying with the program expectations.
6. Fairview Recovery Services Inc. is not responsible for Personal belongings. Fairview Recovery
services, Inc. is not responsible to replace lost or damaged Personal property. Personal belongings
left behind by a resident who leaves, will be held for a period of (30) days. After that time, all
belongings will be considered forfeited and will be disposed of at the discretion of Fairview Recovery
Services, Inc.
Fairview Recovery Services, Inc. Responsibilities: To further your rehabilitation the staff of
Fairview Recovery Services, Inc. agree:
1. To provide you with the following services without regard to your sex, race, religion, national origin,
sexual preference and mental, emotional, or physical condition:
a) Admission and Discharge planning
b) Training in activities of daily living.
c) Case management
d) Supportive counseling Focusing on relapse prevention and monitoring of sobriety.
e) Crisis management (dealing with difficult situations through counseling or other appropriate
interventions)
f) Medication Management
2. To assist you in:
a) Identifying and defining your needs.
b) Developing and individualized rehabilitation plan
c) Identifying appropriate agencies and services to meet your needs
d) Recommending and or referring and coordinating services
e) Identifying and clarifying your satisfaction or dissatisfaction about the services, you are
receiving and helping you to find appropriate methods to express your views.
f) Supporting and reviewing progress and changing your rehabilitation plan, as appropriate,
through regularly scheduled meetings with your primary counselor.
g) Dealing with difficult situations through crisis counseling or other appropriate interventions
3. To treat you and your fellow clients with dignity and ensuring that your personal rights include, but
are not limited to, the:
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a) Right to reasonable privacy
b) Right to confidentiality
c) Right to access to your records as described in agency policies.
d) Right to make and receive phone calls
e) Right to receive visitors
f) Right to send and receive mail unopened
g) Right to voice grievances or complaints about the programs, staff and facility, in an
appropriate manner, without fear of reprisal
h) Right to exercise all other rights guaranteed to citizens of the community
4. To provide your family members/ significant others with an orientation to the program and ongoing
consultation, education and support with the primary purpose of helping them understand and
support you while you are in the program.
I understand that Fairview Recovery Services, Inc. staff is responsible for helping me find
ways to make my stay a growth experience and to help me address situations with which I
am not satisfied.
I understand that I have entered this program voluntarily and may leave voluntarily, having
given proper notice.
I understand that if I am satisfied or not satisfied with something, I am encouraged to
inform staff. A safe environment will be provided and my views will b
e taken seriously.
Resident’s Signature _______________________ Date ____________
Counselor’s Signature ______________________ Date ____________
____ Chart Copy
____ Client Copy
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NEW YORK STATE
OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES
CONSENT TO RELEASE OF INFORMATION
CONCERNING
ALCOHOLISM/DRUG ABUSE PATIENT
LOCADTR ASSESSMENT
Revoked On: ___________ Staff Initials: __________
Patient's Last Name First M.I.
Case Number
Facility Unit
INSTRUCTIONS:
GIVE A COPY OF THIS FORM TO PATIENT! Prepare one (1) copy for the patient's case record. If
this form is to be sent to another agency with a request for information, prepare an additional copy for the
patient's case record.
PATIENT’S CONSENT TO DISCLOSE AND OBTAIN PERSONAL IDENTIFYING INFORMATION
EXTENT OF NATURE OF INFORMATION TO BE DISCLOSED OR OBTAINED:
All information necessary to complete a personalized Level of Care for Alcohol and Drug Treatment Referral “LOCADTR” assessment.
PURPOSE OR NATURE FOR DISCLOSURE/RELEASE AND NAME OF ORGANIZATIONS DISCLOSING AND OBTAINING
PERSONAL IDENTIFYING INFORMATION:
I consent to the disclosure of confidential information to, and between, the New York State Office of Alcoholism and Substance Abuse
Services (OASAS), the OASAS-Certified treatment facility identified above of my clinical treatment including information from the
OASAS Client Data System (CDS) and my Social Security Number.
I understand that the level of care determination assessment will only be shared with me and the OASAS treatment facility identified
above. Unless I have given written permission to share the information with other agencies, programs or payers.
I further understand that non-personal identifying information may be evaluated so that the effectiveness of the LOCADTR assessment
tool can be evaluated.
I, the undersigned, have read the above and authorize the New York State Office of Alcoholism and Substance Abuse Services and the
staff of the OASAS-certified treatment facility named above to disclose and obtain such information as herein specified.
I understand that this consent may be withdrawn by me in writing at any time except to the extent that action has been taken in reliance
upon it. This consent shall expire within six (6) months from its signing, unless a different time period, event or condition is specified
below, in which case such time period, event or condition shall apply. I also understand that any disclosure of any identifying
information is bound by Title 42 of the Code of Federal Regulations (C.F.R.) Part 2, governing the confidentiality of alcohol and drug
abuse patient records, as well as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) 45 C.F.R. §§160 &164; and
that redisclosure of this additional information to a party other than those designated above is forbidden without additional written
authorization on my part.
Any information released through this form MUST be accompanied by the form Prohibition on
NOTE:
Redisclosure of Information Concerning Alcoholism / Drug Abuse Patient (TRS-1)
I understand that generally the program may not condition my treatment on whether I sign a consent form, but that in certain limited
circumstances I may be denied treatment if I do not sign a consent form. I have received a copy of this form.
(Signature of Patient) (Signature of Parent/Guardian)
(Print Name of Patient) (Print Name of Parent/Guardian)
(Date) (Date)
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