YWCA of Western Massachusetts

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YWCA OF WESTERN MASSACHUSETTS SUPPORTIVE HOUSING PROGRAM APPLICATION INSTRUCTIONS

This form must be filled out all at once so please make sure to review the form first and have all necessary information on hand before beginning. If you have any questions please contact the Property Manager at 413-732-3121 x470.

Agreement

Program Description

The YWCA Supportive Housing Program is an 18–24-month supportive housing program that is designed to help survivors 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.

Definitions:

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.
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
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.
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;
- 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 they are:
- Sleeping in an emergency domestic violence shelter or living in other homeless shelter/program because of domestic violence, stalking, sexual assault or dating violence
- 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. Must have a history of domestic violence, dating violence, sexual assault or stalking.
- 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.
- Fleeing domestic violence, dating violence, sexual assault or stalking.
- Has a primary nighttime residence that is a public or private place not meant for human habitation
- 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

Applicant must be a resident of Hampden County

Application Process:

An interview will be scheduled when an apartment is becoming available. Verification of income is required.

Applicant must complete an application and be interviewed by the YWCA’s Supportive Housing Program staff to determine eligibility and the YWCA’s ability to meet their needs (see attached for specific application instructions).
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. If the applicant requires assistance with payment, the YWCA will assist in connecting them with available community resources.
Applicant must be willing to work on an individualized self-sufficiency plan and meet with a case manager weekly or bi-weekly
Applicant must be 18 years or older.
Applicant must demonstrate the ability to live with a diverse population of people and to respect different lifestyles and choices.
Applicant understands that this is a supportive living environment and individuals not covered under the lease cannot reside within the unit.

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. *

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Application for Housing

Project: YWCA Supportive Housing Program

Address: 62 Marcia Haas Circle, Springfield, MA 01118

Telephone: (413) 732-3121

Referral Information

Referring Agency

Contact Name

Contact Address

Contact Phone Number

Contact Email Address

Contact Fax Number

General Information

First Name *

Middle

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Preferred method of contact *

Hours you can be reached: *

Phone Number *

Check all that apply to the phone number: *

It is safe to call this number

It is safe to leave a voice mail

It is safe to text this number

Email Address *

Is it safe to email regarding your application? *

Race *

Ethnicity *

Non-Hispanic/Non-Latino

Hispanic/Latino

Don't know

Prefer not to disclose

Primary Language *

English

Spanish

French

Other Other

Secondary Language(s)

English

Spanish

French

Other Other

Gender Identity *

Sexual Orientation *

Veteran Status *

Victim Type *

Disability *

Bedroom size requested *

Studio

Two BR

Three BR

Handicap BR

Household Composition

Number of Household Members (including yourself as the first entry): *

Member 1 First Name *

Member 1 Last Name *

Member 1 Relationship to
HOH *

Member 1 Birth Date: * +

Do you have a birth certificate and social security card, or a green card? *

Yes

No

Member 1 SS#: * 🛈

Member 2 First Name *

Member 2 Last Name *

Member 2 Relationship to
HOH *

Member 2 Birth Date: * +

Member 3 First Name *

Member 3 Last Name *

Member 3 Relationship to
HOH *

Member 3 Birth Date: * +

Member 4 First Name *

Member 4 Last Name *

Member 4 Relationship to
HOH *

Member 4 Birth Date: * +

Member 5 First Name *

Member 5 Last Name *

Member 5 Relationship to
HOH *

Member 5 Birth Date: * +

Member 6 First Name *

Member 6 Last Name *

Member 6 Relationship to
HOH *

Member 6 Birth Date: * +

Are you currently pregnant? *

What is your approximate due-date? * +

Do you anticipate any other changes in household
composition in the next twelve months? *

Yes

No

If you anticipate changes, please explain: *

Income

Income from Any Source *

Monthly Income *

Monthly Income Sources [Select all that apply]: *

Non-Cash Benefits from Any Source: *

Non-Cash Benefits [Select all that apply]: *

SNAP (Food Stamps)

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

TANF Child Care services

TANF transportation service

Other TANF-funded services

Not Applicable

Other Source Other Source

Additional Information

Have you or any member of your family ever been
convicted of a felony? *

Yes

No

If yes, please describe: *

Pet Information (if applicable)

Do you have any pets or any type of
service and/or support animal? *

Yes

No

If yes, please describe the animal: *

Will any or all of these animals also need housing? *

Yes

No

If yes, please describe the species, age, and any other relevant characteristics of each animal: *

If no, please briefly describe where the animals will live, if you are accepted into transitional housing: *

Certification

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 *

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HOH Signature Date: * +

Applicant Background

A. How did you hear about the YWCA Supportive Housing Program? *

B. Why are you requesting residency in the YWCA SHP? *

C. Current Living Situation *

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

residing in homeless shelter/program as a result of dating violence, stalking, sexual assault or dating violence

prior resident in emergency DV shelter, homeless shelter/program, correctional facility, other transitional housing program or teen living program

Shelter Name: *

Program Name: *

Facility Name: *

Dates of stay: *

D. Do you currently have the ability to pay the deposit and turn on and maintain your electricity? *

Yes

No

E. Criminal Justice History:

Describe any history of arrests or convictions: *

Describe any outstanding criminal justice issues: *

F. Are there any legal and/or personal matters which could interfere with your taking possession and maintaining occupancy in this housing community? Explain *

G. Please provide any information regarding any physical, emotional or psychiatric disabilities or challenges you have, which would be useful for us to know. We ask this with the sole purpose of understanding how we can best serve you and accommodate your needs, including your housing needs. You are welcome to skip this question or only include information you believe is relevant to your participation in Supportive Housing. *

H. Are there any accommodations we can assist you with or provide, to ensure your ability to participate in this SH program? For example, wheelchair accessibility, TTY, large print or Braille, service animals, etc. You are welcome to skip this question or only include information you believe is relevant to your participation in Supportive Housing. *

I. Are you related to any staff member of the YWCA of Western MA? *

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 understand that Wayfinders will be running a background check on me. *

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Applicant Signature Date * +