HRA 2010e Supportive Housing Application

Required Documentation

Below are the required documents needed to complete and submit a 2010e application. All application material must be uploaded to the HRA Placement Assistance and Client Tracking (PACT) system.

Demographic Data

• Name including alias, Address, Borough, Family Composition (if application is for a family), SSN, DOB, Gender, Income/Entitlements, Education, Marital Status, Ethnicity, Primary Language, Citizenship, Important Contacts
• Verification that the HIPAA Compliant Authorization is signed by applicant and the agency has a record of the original form

Current Housing Location

• Housing/Homeless history including dates; Housing type, Facility name, Street address. If applicant was homeless on the streets or non-municipal shelters, documentation must be attached to the application providing more specific information including dates of homelessness and description of homelessness (places stayed, the more specific the better)

Clinical Assessment

• Clinical Disorders and Other Conditions that may be a focus of Clinical attention as defined by the DSM-IV-TR or DSM-5
• Assisted Outpatient Treatment (AOT) or Assertive Community Treatment (ACT) status

Activities of Daily Living

• Checking any ADLs the applicant may require assistance with due to a medical or mental health conditions previously indicated. Provide explanation for any items checked. List includes: Feeding and Meal Preparation; Housekeeping; Managing Finances; Personal Hygiene; Traveling: Hearing; Sight; Cognitive Functions

Medications

• List names of psychotropic and non-psychotropic medication in appropriate category. Indicate level of support applicant will need to maintain medication compliance once they are housed

Current Treatment/Service Providers

• List of applicant’s current treatment and service providers, including, but not limited to, medical, mental health and case management services providers/programs, Health Home
• Managed Long Term Care (MLTC) / Insurance provider

Domestic Violence

• If applicant was a victim of DV, information about the services received and how long ago the domestic violence occurred

Hospitalization History

• Age of first psychiatric hospitalization; # of psychiatric hospitalizations in the past 3 years; Name of hospital, dates of admission/discharge and service (psychiatric or medical)

Health and service providers in need of more information on the HRA PACT system can contact the PACT technical user support at 929-221-4515 or email hracassupport@hra.nyc.gov.

For assistance completing the 2010e, contact CUCS (www.cucs.org) at (212) 801-3300.