Housing Application - BIMA Services

INTAKE PROCESS 2021

2021
You must provide the following with application
- Completed release of information ( See below)
- Completed application
- Provide copy ID ( call if unable to submit with application)
- Proof of income
- Email to: info@bimaservices.org or fax 253-302-3492
- Contact 206-393-2273 with any questions
IF SELECTED
- Pay non refundable processing fee + first and last program fee
- Offer single and shared rooms
- Complete Release of information for background check
- Pay 25.00 Background check after approved
BIMA Services offers shared living housing to men and women 25 years and older that need a place of restoration to address a broad range of needs. The program helps individuals to believe in themselves again to achieve and sustain a higher quality of life
Consent Authorization for Release of Information
First Name* Last Name* authorize the below agency to release information of me to BIMA Services for the purpose of one or more of the following: Housing, drug and alcohol treatment information, referrals, psychosocial /mental health treatment, medical information related to emergencies, housing referrals, income verification and medications for the purpose of coordination of care and housing. ( name of agency that referred you).
Name of agency that referred you area code Phone Number I, also give BIMA Services permission to complete a Background check for the purpose of housing. I give BIMA specific authorization to obtain information for 1. Housing, 2. Criminal history.
Who( name of person) referred you
Telephone number of the person who referred you

Area Code Phone Number
I authorize all of the above and also for the records/information to be given in the following ways:

Written/photocopy/paper, Eletronic format, fax, and verbal
Date*

MonthDay Year
Date
Date of birth*
Name*

First Name Last Name
I understand that my records may contain information regarding Sex offense (Per RCW 4.24.550, (5)). I give specific authorization for these public records to be released.

I also understand that pursuant to RCW 43.43.838. Will conduct a background check through the Washington State Patrol for the purpose of perspective residents for housing. The background check is for initial housing decision.

I understand that this authorization is voluntary and that I may refuse to sign it. I will be provided a copy of this signed authorization, if requested. A photocopy of this authorization is as valid as the original.

I understand that I may withdraw or revoke my permission at any time. If I withdraw my permission, my information may no longer be used or released for the reasons covered by this authorization. However, any disclosures already made with my permission are unable to be taken back. I may revoke this authorization by notifying Concerto Medical Center in writing.

I understand that my records may contain information regarding mental health, diagnosis and treatment, drug and alcohol abuse which is protected (per 42CFR, Part 2), the testing diagnosis, or treatment of HIV/AIDS and or sexually transmitted diseases (Per RCW 70.24.105). I give specific authorization for these protected records to be released

Unless revoked earlier, this authorization expires in one year unless I specify another time: __________________________

I release BIMA named in this authorization from legal responsibility or liability for the release of the health record as authorized on this form. I understand that this authorization is voluntary and that I may refuse to sign it. I will be provided a copy of this signed authorization, if requested. A photocopy of this authorization is as valid as the original.
Name*

First Name Last Name
Date*

MonthDay Year
Date
BIMA Application
Applications will expire after 60 days. If eligible, applicants will need to go through our interview process as well as be approved for shared housing. Receiving this screening packet does not guarantee that you will be housed in our program. Applicants are encouraged to continue their search housing.
Date Received by BIMA: ___________

(agency use only)

Approved_______ Denied _______ Date______________
Demographic Information
Name*

First Name Middle Name Last Name
Phone Number*

Area Code Phone Number
Mailing Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Married/Separated*

Married/SeparatedWidowedSingleDivorcedLong term partner
Gender*

MaleFemale
Are you currently Pregnant?*

YesnoN/A
If Pregnant, How many months are you pregnant?
When is your expected due date?
Your DOB*
Your Age*
Your Social Security Number*
Email
example@example.com
Ethnicity/Race*
Please describe some of the goals you have obtained in the past year*
What are some future goals you would like to accomplish?*
What areas do you feel you could use additional support in?
Please add anything else you feel we should know that would be beneficial in supporting you.
Have you EVER engaged in treatment or counseling, check all that apply*

Mental Health Out PatientSubstance use Out PatientSubstance use Inpatient facilitiesMental Health Inpatient facilitiesN/A
If you answered yes, please describe your experience with counseling/treatment or inpatient experience
Is applicant CURRENTLY receiving case management services and/or other assistance such as check all that apply*

Mental Health ServicesSubstance Use TreatmentOtherN/A
If OTHER, Please describe
Does applicant have a history of Domestic Violence?*

yesNo
If you answered YES, please explain.
Is there a protection order against you*

YesNoN/A
If fleeing from domestic violence, is there a Protection Order in effect?*

YesNoN/A
Does applicant have a recent history (last 2 years) of alcohol or chemical abuse/addiction?*

N/AYesNo
If yes, was is applicant last date of use or type N/A if not applicable*
Drug of choice
Has applicant ever completed substance abuse treatment?*

N/AInpatientOut patientCurrently in treatment
If YES, what date did you graduate/complete treatment?
If currently in treatment, name of facility
Rental History Answering yes in this section will not necessarily disqualify you.
Last Permanent address*
City, State, Zip code*
Briefly described the events that caused you to be homeless*
How long have you been homeless*
Do you owe money to a Landlord?*

Owe money to a Housing AuthorityOwe money to a LandlordN/A
Have you Ever been evicted?
SOURCE OF MONTHLY INCOME, EMPLOYMENT
Are you currently employed*

YesNoN/A other income
Name of employer
Type of employment*

Part-timefull-timeon-callTemporaryN/A
Monthly income from job is none type 0
Other sources of income*

SSISSDISSAChild SupportVoucher ProgramTANFVoucher program
Monthly amount of other sources of income
If Voucher program, what is the name of program?
Does you have a bank account*

YesNO
Do you have a payee*

YesNo
If yes, provide name
Education
What is the highest level of education?*
Are you currently enrolled in school

YesNo
If yes, Name of School
Legal

Applicant must not distort any of the truth when completing the application. Criminal history does not necessarily disqualify you from BIMA however, recent felonies (within 6 months) will be considered on case by case basis.
Are you currently incarcerated or in work release?*

YesNOCurrently in work release
if incarcerated, What is your DOC Number?
If currently incarcerated or at work release, how long have you been incarcerated or mark N/A
If released from prison in the last 12 months: What WAS your date of release or mark N/A
According to RCW 4.24.550 Sex offenders and kidnapping offenders—Release of information to public—Web site. Are you subject to register as a sex offender in any State?*

YesNO
List and explain ALL other conviction in the last 7 years
(answering yes to this question in this section will not necessarily disqualify you) most felony convictions accepted.)
Have you ever been convicted of a crime? If yes, Please list below*

YesNON/A
1. Criminal charge*

FelonyMisdemeanorN/A
List conviction and conviction date*
Criminal charge

FelonyMisdemeanor
List conviction and conviction date
Criminal Charge

FelonyMisdemeanor
List conviction and conviction date
Criminal charge

FelonyMisdemeanor
List conviction and conviction date
If released from prison in the last 12 months: What was your date of release
Are you on DOC currently?*

Yesno
Name of CCO officer
Print your FULL NAME will be considered a digital signature and you acknowledge that the information you have provided is true and complete to the best of your knowledge.
Date*

MonthDay Year
Date
Name*

First Name Last Name
How would you rate the application process?*
Please verify that you are human*
Type any additional questions here
Should be Empty:

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INTAKE PROCESS 2021

Consent Authorization for Release of Information

BIMA Application

Demographic Information

Rental History Answering yes in this section will not necessarily disqualify you.

SOURCE OF MONTHLY INCOME, EMPLOYMENT

Education

Legal