Instructions: Complete this form by providing all of the required information. NOTE: Permanent Supportive Housing (PSH); high priority homeless (HPH); people with disabilities (PWD)

General Information	
Development Name	     	Anticipated Start Date	     	
Primary Service Provider(s) for all PSH units (HPH; PWD: and other PSH units) 	     	

1.	Enter the housing unit distribution for this property. 
Total Housing 
Units	Total PSH Units	Total HPH Units/ Household Type (single; adult; families; youth)	Total PWD Units	Total PSH Units Serving People Leaving Institutions 
(not PWD)	Total PSH Units Serving Other Homeless Populations
(not HPH)	Total PHS Units Serving Other Population	
     	     	     	     	     	     	     	

2.	Describe any specific sub-populations (e.g., victims of domestic violence, veterans, persons with serious mental illness or substance use disorder (SMI or SUD) or specific tenant characteristics for the HPH and any other supportive housing units. 
     

3.	Describe the coordination process with the Coordinated Entry (CE) system for HPH units and other PSH units referred through CE, including how available units are listed and how referrals for the population to be served are made and accepted. 
     

4.	If there are other PSH units not utilizing CE, describe: 
a.	How potential tenants will be assessed for need for PSH
     
b.	The referral process for these units 
     

5.	Describe eligibility screening, documentation and assessment procedures conducted by the primary service provider for all PSH units. 
     

6.	Describe any requirements for occupancy beyond a standard lease (e.g., service participation, sobriety) and any lease addendums for all PSH units. 
     

7.	Describe the supportive housing model and philosophy for assisting people who are experiencing homelessness. If the project has other PSH units, include the supportive housing model and philosophy for assisting these populations. Answers should include references to evidence-based practices and how you will successfully implement them for your selected population. 
     

8.	Service Delivery
a.	Indicate the level of support provided by the primary service provider for all PSH units. Choose only one, deleting the one that does not apply. 
Case Management (cannot be paid for with operating budget) OR Tenant Service Coordination

b.	Describe how the primary service provider will provide services to tenants. 
     
c.	Describe how the primary service provider will actively work to engage tenants in supportive services.
     
d.	Describe how the primary service provider will work to prevent eviction or loss of housing for the supportive housing tenants. 
     
e.	Describe how the primary service provider will coordinate referrals to services provided by other entities on-site or in the community (reference the services outlined in the service table below).
     
9.	In the table below, indicate the supportive services for each service set:
•	Include supportive services offered by the primary service provider, and 
•	Include supportive services available from other service partners and referral resources 
Type of Service	Name of Primary Service Provider or the Specific Referral Entity Providing Service or Support	Enter an “X” if Service is Available On-site	Service Availability (e.g., 24/7; business hours; evenings; 12:00 – 8:00; weekends; by appointment)	
Basic Service Set	
Benefits Assistance	     	     	     	
SOAR services 	     	     	     	
Financial management/budget	     	     	     	
Independent living skills	     	     	     	
Education, employment training/readiness	     	     	     	
Safety	     	     	     	
Community involvement/social support/recreation	     	     	     	
Health support	     	     	     	
Parenting training, mentoring	     	     	     	
2-Gen Assessment and Services
List:	     	     	     	
Children’s Service Set (e.g., education, truancy, behavioral health) 	
List:      	     	     	     	
List:      	     	     	     	
Substance Use Disorder Services Set	
List:      	     	     	     	
List:      	     	     	     	
Adult Mental Health Services Set (includes ACT, ARMHS, CSP, TCM) 	
List:      	     	     	     	
List:      	     	     	     	
Co-occurring Disorders Service Set	
List:      	     	     	     	
Traumatic Brain Injury Service Set	
List:      	     	     	     	
Physical Disability Service Set	
List:      	     	     	     	
Home and Community Based Services (includes CADI, BI, CAC and Elderly Waiver services)	
List:      	     	     	     	
Other services	
List:      	     	     	     	
List:      	     	     	     	

10.	Which staff position(s) will be responsible for HMIS data collection, data entry and reporting for HPH units? 
     

11.	How will you measure program success? Describe specific outcome goals for the program and participants (may include outcomes such as housing stability, income, employment, education, health, etc.). 
Outcome Goal	Outcome Measure	
     	     	
     	     	
     	     	

12.	Describe rental assistance resources for all PSH tenants. 

Subsidy Type	# of Units	
Project-based Section 8 Rental Assistance	     	
HUD CoC Rental Assistance – Project-based	     	
HUD CoC Rental Assistance – Sponsor-based	     	
HUD Continuum of Care (CoC) Rental Assistance – Tenant-based	     	
HUD CoC Operating Funding	     	
Housing Support (fka Group Residential Housing- GRH)	     	
Veterans Affairs Supportive Housing (VASH) 	     	
Other subsidy type:      	     	
No subsidy: Rents set at supportive housing  levels	     	

13.	Add additional information about the supportive housing service plan that has not already been described. 
     

14.	Complete the supportive housing sources and uses budget below. 

Description of Activity, Staff or Program Related to Supportive Services
(include FTE %),	Name of Organization Responsible for Obtaining Funding to Cover Activity, Staff, or Program	Budget Amount 
(12 month) 	Approved Funding 
($ Amount) 	Funding Source	Amount of Unfunded Budget	Funding Source/Plan for Unfunded Amount	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
	TOTAL:	0	0		0		
Description of Activity and Staff Related to 
Front Desk and Security
 (include FTE %)	Name of Organization Responsible for Obtaining Funding to Cover Activity and Staff	Budget Amount 
(12 month)	Approved Funding 
($ Amount) 	Funding Source	Amount of Unfunded Budget	Funding Source/Plan for Unfunded Amount	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
     	     	     	     	     	     	     	
	TOTAL:	0	0		0