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Waiting List Application

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BROWARD HOUSING SOLUTIONS®

Waiting List Application

Broward Housing Solutions® mission is to provide safe, supportive, and permanent housing to clients
with low income and severe and persistent mental illness.

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Initial Eligibility / Documentation

Does this candidate demonstrate the ability to live independently?
Diagnosis attached?

Applicant Personal Information

Phone No.
Unit Type (Please Select One)

Sources of Income

Minimum Price: $10.00
Minimum Price: $10.00
Minimum Price: $10.00
Minimum Price: $10.00
Minimum Price: $10.00
Minimum Price: $10.00
Minimum Price: $10.00

Demographic Information

Race
Gender
Ethnicity
Disabled Veteran

Areas of Interest

Checkboxes

Other Household Member Information

Applicant Eligibility / Program Notes

Please note: All adults over age 18 must have income unless a full-time student. All full-time students over age 26 must have income. Battery charges less than 3 years old will not be considered. Clients must qualify for mental health case management with an approved agency. Clients deemed capable of living independently should be able to follow their mental health case management plan, manage finances, maintain sanitary housing, and adhere to the rules set by the landlord

Fair Housing Notice

Per the Fair Housing Act, Florida Law Prohibits Discrimination on the basis of race, color, national origin, religion, sex,familial status (including children under the age of 18, living with parents or legal custodians, pregnant women, and people seeking custody of children under the age of 18,) and disability.Additionally, Broward County prohibits discrimination in housing based on sexual orientation, age and marital status

Case Management / Verification

Supervisor / Manager Signature
Case Manager Signature

BROWARD HOUSING SOLUTIONS®

Waiting List Application

Broward Housing Solutions® mission is to provide safe, supportive, and permanent housing to clients
with low income and severe and persistent mental illness.

Please enable JavaScript in your browser to complete this form.

Initial Screening Questions

1. Has this client previously lived at/been a resident of Broward Housing Solutions (BHS)?
2. Does this candidate demonstrate the ability to live independently?
3. Does this client have a severe and persistent mental illness (SPMI)?
4. Is the client currently homeless?
5. Has the client experienced chronic homelessness?

Applicant Information

Demographics

Name

Sources of Income (Please Fill in all that apply, if unknown please enter 0)

Frequency of income:

History

Has the client ever signed a lease agreement? (Please Check One)
Has the client ever been evicted?
Has client ever been arrested (Please Check One)
Was the client ever convicted of a misdemeanor or felony?

Preference

Veteran (Please Check One)
Disabled Veteran (Please Check One)

Referring Agency

Applicant Household Member Information

Name
Supervisor Name
Please note:

All adults 18 - 26 must have income or enrolled in school full-time. Felony charges such as violent crimes, fraud charges, drug trafficking or registration on the sex offender registry within the last 7 years will not be considered. All clients must have mental health case management with an approved agency. Clients deemed capable of living independently must follow their mental health case management plan, manage finances, maintain sanitary housing, and adhere to the rules set by the landlord. Per the Fair Housing Act, Florida Law Prohibits Discrimination on the basis of race, color, national origin, religion, sex, familial status (including children under the age of 18 living with parents or legal custodians, pregnant women, and people seeking custody of children under the age of 18,) and disability. Additionally, Broward County prohibits discrimination in housing based on sexual orientation, age, and marital status.


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