Supportive Housing Request Form

Supportive Housing Request Form
The North Texas Behavioral Health Authority (NTBHA) has been awarded Supportive Housing funds that will assist individuals:
- who are at risk of losing housing or without housing;
- have a mental health or substance use diagnosis;
- and are in crisis.
These funds are available for individuals who meet a certain criteria.

By completing this application and screening form, NTBHA will review all funding options that the applicant may be eligible for.

*Disclaimer: There is certain information that is needed regarding a person's mental health and substance abuse diagnosis. NTBHA will protect this information according to HIPAA and privacy laws including, but not limited to state and federal laws.*

To complete this process we will need the following documents:
- Release of Information & Consent
- W9, lease, and ledger from landlord
Questions/Comments:
SupportiveHousing@ntbha.org
- Name
  
  PrefixFirst NameMiddle NameLast Name
- Social Security #
- Birthdate
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Race
- Gender
- Ethnicity
- Marital Status
- Email
- Cell Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Do you have a Mental Health or Substance Use Diagnosis
- Are you currently receiving services with a NTBHA Provider
- Name of Provider
- Behavioral Health Case Worker Information:
  
  Caseworker NameEmail Address or Contact #
- Do you currently receive any of the following?
- ** If you receive assistance from any other program, please do not proceed with application**
- Are you currently without housing/shelter?
- Do you need assistance securing housing or shelter options?
- Current Housing/Shelter Location:
  
  Current Location: Homeless, Emergency Shelter, Apartment, etc
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- County of Residence
- Is the current address different than the location where you are asking for rental assistance to?
- Property (Requesting rental assistance for)
  
  Name of Apartment, Boarding Home, Transitional Program, etc
  
  Street Address
  
  CityState / Province
  
  Postal / Zip Code
- Name Landlord/Owner (contact person to discuss payment, if approved):
  
  First NameLast Name
- Phone Number for Landlord/Owner
  Please enter a valid phone number.Format: (000) 000-0000.
- Landlord/Owner Email Address
  example@example.com
- Property Name (Apartment or Boarding home or other program location)
  
  Name of Apartments, Boarding Home, or Transitional Housing/Program Name
  
  Street Address
  
  CityState / Province
  
  Postal / Zip Code
- Monthly Rent $
- Past Due Rent $ Owed
- Check Payable to:
- Please list all current income source(s): SSI, SSDI, Foodstamps, etc
- Do you or your spouse have any other income?
- COMMENTS
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Signature of Applicant
- Signature other person completing form if not applicant (If applicable)
- Should be Empty: