YWCA of Western Massachusetts

Application for Housing
(Supportive Housing Program  and Young Parent Program)
This form must be filled out all at once so please make sure to review the form first and have all necessary information (such as insurance, finances, SS#s, etc) on hand before beginning.  If you have any questions please contact Aisha Pizarro at (413) 732-3121.
You may upload supporting documentation below. If you do not upload the documents now you must provide them at the time of your interview.


Program Description

The YWCA Supportive Housing Program is an 18-24 month supportive housing program that is designed to help women achieve independent living situations within the community. Monthly rent provides women with an apartment, laundry facilities, case management services and group meetings. Residents set self-sufficiency goals with a case manager and work toward the achievement of those goals by participating fully in the program.

Criteria for Acceptance and Participation: 

  • Applicant must have a history of being a victim of domestic violence, dating violence, sexual assault or stalking and submit certification form
  • Definitions:
    • A. Domestic Violence – includes actual or threatened acts of violence committed by a current or former spouse of the victim, by a person with whom the victim shares a child in common, by a person who is cohabiting with or has cohabited with the victim as a spouse or partner or by any other person against an adult or youth victim who is protected from that person‘s acts under the domestic or family violence laws of the jurisdiction. Domestic violence can be physical, sexual, emotional, economic, or psychological actions or threats of actions that influence another person. This includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound someone.
    • B. Dating Violence – violence committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim; and where the existence of such a relationship shall be determined based on a consideration of the following factors:

      • The length of the relationship
      • The type of relationship
      • The frequency of interaction between the persons involved in the relationship
    • C. Sexual Assault- defined as any type of sexual contact or behavior that occurs without the explicit consent of the recipient of the unwanted sexual activity. Falling under the definition of sexual assault is sexual activity such as forced sexual intercourse, sodomy, child molestation, incest, fondling, and attempted rape.
    • D. Stalking – means –

      • (A) (i) to follow, pursue, or repeatedly commit acts with the intent to kill, injure, harass, or intimidate another person; and (ii) to place under surveillance with the intent to kill, injure, harass or intimidate another person; and
      • (B) in the course of, or as a result of, such following, pursuit, surveillance or repeatedly committed acts, to place a person in reasonable fear of the death of, or serious bodily injury to, or to cause substantial emotional harm to
        • (i) that person;
        • (ii) a member of the immediate family(spouse, parent, brother, sister, or child of that person)
        • (iii) any other person living in the household of that person and related to that person by blood or marriage of that person; or
        • (iv) the spouse or intimate partner of that person;
    • E. Perpetrator – means person who commits an act of domestic violence, dating violence sexual assault or stalking against a victim.

    • Applicant must be homeless or on the verge of homelessness: An individual is considered homeless if she is
      • sleeping in an emergency domestic violence shelter
      • residing in other transitional housing program for domestic violence for past 12 months and unable to identify long-term permanent housing option
      • aging out of a Teen Living Program and unable to identify long-term permanent housing option
      • being discharged from a correctional facility and having no subsequent residence identified and lacking the resources and support networks needed to obtain access to housing.
      • Living in other homeless shelter/program as a result of domestic violence, stalking, sexual assault or dating violence
      • We will also consider applications from those who have discharged from one of the above and a supportive housing program would assist them in becoming more self-sufficient

    Documentation necessary to determine eligibility will include letter of referral/reference from such organization in which person resides when the application comes to the top of waitlist

    • Applicant must be a resident of Hampden County
    • Applicant must be currently involved in employment, employment training, school or volunteer work (or a combination thereof) for at least 30 hours per week and submit verification of current status or pending enrollment in such activity

Application Process

An interview will be scheduled when an apartment is becoming available. Verification of income is required; the process will be much quicker if verification is attached to this application.

  1. Applicant must complete an application and be interviewed by the YWCA’s Supportive Housing Program staff to determine her eligibility and the YWCA’s ability to meet her needs (see attached for specific application instructions).
  2. Applicant must demonstrate ability to pay for electricity in the unit. The applicant must also pay an initial security deposit equal to 1st months rent.
  3. Applicant must be free from drug or alcohol dependence.
  4. Applicant must be willing to work on an individualized self-sufficiency plan and meet with a case manager weekly or bi-weekly
  5. Applicant must be 18 years or older.
  6. Applicant must demonstrate the ability to live with a diverse population of women and to respect different lifestyles and choices.
  7. Applicant must be engaged in 30 hours of weekly employment, volunteering or educational activities
  8. Applicant understands that this is a supportive living environment and overnight visitors will not be allowed. Violation of this policy is grounds for eviction.
  9. Group programming and tenant meetings are mandatory

Agreement to participate in services

I have applied for residency at the YWCA. If accepted into the program, I agree to abide by the conditions listed above, and I understand that the purpose of the program is to help me achieve greater independence. *

Application for Housing

Project: YWCA Supportive Housing Program

Address: 62 Marcia Haas Circle, Springfield, MA 01118

Telephone: (413) 732-3121


Referral Information

Applications are placed in order of date and time received. An applicant may be interviewed only after the receipt of this tenant application.

General Information

Race *
Ethnicity *
Primary Language *
Secondary Language(s)
Disability *
Bedroom size requested *

Household Composition

Member 1 Student? *
Member 2 Student? *
Member 3 Student? *
Member 4 Student? *
Member 5 Student? *
Member 6 Student? *
Have there been any changes in household composition
in the last twelve months? *
Do you anticipate any changes in household composition
in the next twelve months? *
Is there someone not listed above who would normally be
living with the household? *
Will all of the persons in the household who are or have been full-time students during five calendar months of this year or plan to be in the next calendar year at an educational institution (other than correspondence school) with regular faculty and students? *
Are any full-time student(s) married and filing a joint tax return? *
Are any student(s) enrolled in a job-training program receiving assistance under Job Training Partnership Act? *
Are any full-time student(s) a TANF or title IV recipient? *
Are any full-time student(s) a single parent living with his/her minor child who is not a Dependant on another's tax return and whose children are not dependents of anyone other than a parent? *
Is any student a person who was previously under the care and placement of a foster care program (under Part B or E of Title IV of the Social Security Act)? *


Check off ALL sources of income of Household Members: *
Are you legally entitled to receive alimony? *
Do you receive alimony? *
Are you legally entitled to receive
child support? *
Do you receive child support? *
Do you anticipate any changes to this income in the next 12 months? *
Is any member of the household legally entitled to receive income assistance? *
Is any member of the household likely to receive income or assistance (monetary or not) from someone who is not a member of the household? *
Is the income received? *


Select all types of assets: *
Does any member of the household have an asset owned jointly
with someone who is NOT a member of the household? *
Do they have access to the assets? *
Have you sold/disposed of any property in the last 2 years? *
Have you disposed of any other assets in the last 2 years
(For example, given money to relatives)? *
Do you have any other assets not listed above
(excluding personal property)? *

Additional Information

Are you or any member of your family currently using an illegal substance? *
Have you or any member of your family ever been
convicted of a felony? *

Emergency Contact

Vehicle and Pet Information (if applicable)

Do you have any pets or any type of service and/or
companion animal? *
Will any or all of these animals also need housing? *


I/We hereby certify that I/We Do/Will Not maintain a separate subsidized rental unit in another location. I/We understand I/We must pay a security deposit for this apartment prior to occupancy. I/We understand that my eligibility for housing will be based on applicable income limits and by management’s selection criteria.

I/We certify that all information in this application is true to the best of my/our knowledge and I/We understand that false statements or information are punishable by law and will lead to cancellation of this application or termination of tenancy after occupancy. All adult applicants, 18 or older, must sign application.

Head of Household Signature *

Applicant Background Section

C. Current Living Situation *
D. Previous Rental History
E. Do you currently have the ability to pay the deposit and turn on and maintain your electricity? *
F. Are you currently enrolled in school or a training program? *
G. Are you currently volunteering or performing community service? *
H. Are you currently employed? *
J. Criminal Justice History:
I certify the information in this application is true and correct. I authorize the YWCA Supportive Housing Program to contact the sources listed in this application for the purposes of verifying the accuracy of the information. In addition, I also authorize the YWCA Supportive Housing Program to conduct a search of National Sex Offender Public Registry as part of determining my eligibility for the program. *
Powered byFormsite