Lake County Rental Assistance (LCRA) Application

Welcome to the Lake County Rental Assistance (LCRA) Application! The LCRA program is for eligible low-income Lake County households financially impacted by COVID-19. Households must be eligible and provide all required documentation in order to receive assistance. This program is for residents of Lake County, Illinois.

Instructions:

Only one form should be submitted for the household. Please fill out this form to the best of your ability. If the form is incomplete when submitted, your LCRA provider will reach out to you to complete the form. You may be asked to provide additional documentation.

Please submit this form only once. Submitting multiple forms per household may delay processing. Filling out this form does not guarantee assistance.

Before you fill out this form, you will need:

• An email address and phone number where you can be reached.
• An email address and phone number for your landlord or property manager.
• Your signed lease.
• Documentation of all your income.
• If you received unemployment after March 13, 2020, you will need documentation of this.
• A Government Issued Photo ID

Please make sure you have this information before you begin the application.

Please note, if you have received 6 months or more of rental assistance from a previous program, you will not be eligible for LCRA assistance.  Please call 211 to be refered to other programs for assistance.

What is your household's monthly gross (pre-tax) income (broken out in the categories below)? Please include combined income from all household members.

The LCRA program prioritizes households with income at or below 30% AMI or households with one or more household members who have been unemployed for 90 days or more. Please indicate if one or both of these criteria apply to your household. You may be asked to provide additional documentation.

Name: {name5}

Address: {unitAddress}

The Lake County Rental Assistance (LCRA) Program will remit rent payments on behalf of approved program recipients directly to the recipient’s landlord or property owner. A complete application for rental assistance includes paperwork that must be completed and submitted by the applicant’s landlord or property owner. In signing this consent form, I am authorizing the program provider to contact my landlord and/or property owner to request information, including but not limited to, rent and payment information and I hereby authorize my landlord to release such information. I also authorize the provider to release my information to my landlord which is deemed necessary to complete my application and receive assistance. I authorize my information to be transmitted via any method, including U.S. Postal Service, fax, and email.

Landlord Name: {landlordName}

Landlord Phone Number: {landlordPhone}

Lanlord Email: {landlordEmail}

Monthly Rent: {monthlyRent}

In signing this consent form, I further authorize the provider of this program to disclose information about my application and program recipient status to program funders, as deemed necessary, to comply with grant requirements. I understand that my authorization will remain effective from the date of my signature through the duration of my participation in the program, and that the information will be handled confidentially in compliance with all applicable state and federal laws. I understand that I may revoke the authorization at any time by written and dated communication.

I have read and understand by signing below, I certify that I am giving permission for the provider to obtain or share information for emergency rent and utility assistance.

In order to provide faster and more definitive linkages to needed services, Lake County utilizes a computer system called “ServicePoint®.” ServicePoint® is an information system that helps us improve service delivery and evaluate the effectiveness of services provided. The ServicePoint® system will be shared among Lake County agencies that have signed an agreement with Lake County and are participating in ServicePoint® (the “Participating Agencies”).

TO WHOM INFORMATION WILL BE DISCLOSED TO AND RECEIVED FROM VIA SERVICEPOINT®:

• Employees and staff of this Participating Agency
• Participating Agencies in ServicePoint®. A listing of the Participating Agencies is available to you upon request. A more frequently-updated listing can be found at www.lakecountyil.gov/1957/ServicePoint, which is subject to change. You may also obtain the most current listing by requesting a copy from this Participating Agency
• The ServicePoint® System Administrators at Lake County have access to information for the purpose of maintaining the database

SPECIFIC INFORMATION THAT WILL SHARED VIA SERVICEPOINT®:
By signing this document, you understand that the following information (the “Protected Health Information”) may be used and disclosed by and among the Participating Agencies:

• Name
• Social Security number
• Demographics
• Contact information
• Emergency contact information
• Case manager contact information
• Employment and education information
• Residential and homeless history
• Income, employment and benefit information
• Health insurance and provider
• Information on service referrals
• ServicePoint agency engagement including intake and exit dates
• Basic identifying information on other household members

Your information may be shared by and among Participating Agencies to facilitate the services we provide you and to better serve you and your needs.

• You can revoke this authorization at any time by writing to the Participating Agency which provided you a service.
• You understand that your revocation is not effective to the extent Lake County and/or a Participating Agency has relied on this authorization to store, use or disclose your Protected Health Information.
• If you revoke this consent, no further Protected Health Information will be entered in or used and/or disclosed with Participating Agencies through ServicePoint®.
• We will not condition any services, treatment or any payment(s) on whether you sign this authorization.
• You agree to discuss any questions and/or concerns with the Participating Agency and that you will be provided a signed copy of this authorization.
• You understand that information disclosed pursuant to this authorization may be redisclosed and may no longer be protected by applicable state or federal law.

I have read and understand the above material and I hereby consent that Lake County and the Participating Agencies use, disclose, enter, transmit, and share the Protected Health Information for me or my child(ren)/ward(s)/dependent(s) identified below using ServicePoint® and, if I am between the ages of 13-17, to share Protected Health Information with my parent or guardian.

Name: {name5}

Address{unitAddress}

Consent To Services

Welcome to Catholic Charities of the Archdiocese of Chicago. This Consent to Services form is designed to give you important information regarding services that Catholic Charities provides. Depending on the services you receive from Catholic Charities, you may have certain rights under state and federal laws. Some of these rights are summarized below.

Confidentiality: Clinical records of Catholic Charities clients are confidential and are safeguarded as required by law and Catholic Charities’ policies. Clients will receive “Notice of Privacy Practices” which provides information regarding your rights under HIPAA, 42 C.F.R. Part 2, and state mental health confidentiality laws, if applicable. Disclosure of confidential information is generally made only with your written consent. Exceptions to this policy include, without limitation, the following: (a) When a court orders the release of your records; (b) when there is knowledge of, or reasonable cause to believe, a minor or vulnerable adult is being abused or neglected; (c) when it is believed there is serious, foreseeable and imminent danger of physical harm or violence to you, other identified persons or the community, (d) for quality assurance reviews, licensing, agency accreditation and audit or evaluation by funding bodies, and € as otherwise required by law.

CLINICAL RECORDS: Clients have a right to see their clinical records.  If a client is under 12 years old, the client’s parents or guardian may access the records without the client consent.  If a client is between 12 and 18 years old, a parent or guardian may see the records in certain circumstances, depending on the services provided.

GRIVANCES: If you have a concern about the services being provided, or decisions made about you, you (or a parent or guardian if allowed by law) may discuss the matter informally with the director of the program or department involved.  You may also file a grievance in writing with the director of the program or department involved.  If not resolved, you may send the grievance to the next management level personnel.  If the grievance continues unresolved, the grievance may be sent to the Vice President of the Service Area or designee.  Lastly, an appear to the Senior Vice President of Program Development and Evaluation of Catholic Charities may be initiated.  A copy of the complete Client Grievance Procedures will be made available upon request.

INDIVIDUALIZED SERVICE PLAN: Clients have the right to adequate care, based on an individual service plan in a setting appropriate for the services involved.  The plan shall be formulated and reviewed periodically with the client and/or parent/guardian.

WITHDRAWL OF CONSENT TO SERVICES: I understand that I have the right to ask questions and to be informed regarding any services in which I am asked to participate.  I further understand that while I may withdraw this consent to participate in services at any time, if I do so, my services with Catholic Charities will be terminated immediately.

FOR MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT: I HAVE BEEN INFORMED OF ALL THE RISKS AND ANY COSTS ASSOCIATED WITH TREATMENT TO BE PROVIDED, INCLUDING INFORMATION REGARDING THE NATURE OF THE TREATMENT, POSSIBLE ALTERNATIVES TO TREATMENT AND THE POTENTIAL RISKS AND BENEFITS OF TREATMENT.

I HAVE READ THE ABOVE STATEMENTS OR HAVE HAD THEM READ AND EXPLANIED TO ME IN A LANGUAGE WHICH I UNDERSTAND.  IND ADDITION I HAVE RECEIVED A COPY OF THE CATHOLIC CHARITIES’ CLIENTS RIGHTS AND RESPONSIBILITIES.  I HERBY CONSENT TO THE PROVISION BY CATHOLIC CHARITIES OF ANY AND ALL APPROPRIUATE SERVICES TO ME, OR MY CHILD OR WARD.

In appropriate circumstances, signatories may be requested to furnish identification. Witness has reasonable belief of the identiy of the person signing.

Information on a Minor’s Consent to Services

A minor is defined as a person under the age of 18.  Staff should consult Agency Policy D-7, Services to Minors, for additional information regarding Services to Minors as this is just a summary of information on a minor’s consent to services.

In general, the consent of a parent or guardian is required for a minor to obtain services.  However, There are some exceptions to this, including the expectations below:

A. Substance Use Disorder Care

Minors between the ages of 12 and 18 who are seeking substance use disorder treatment of themselves or who have a family member who abuses drugs or alcohol, may consent to receive health care services or counseling related to the diagnosis or treatment of the substance use.

B. Mental Health Care

Minors between the age of 12 and 18 may consent to confidential outpatient counseling or psychotherapy.  If the minor is between the ages of 12 and 17, the outpatient counseling or psychotherapy services shall be initially limited to not more than eight (8) ninety-minute (90) sessions.  For additional services without parental consent, please consult Agency Policy D-7, Services to Minors.

C. Victim of Criminal Sexual Assault/Abuse

A minor may consent to counseling, diagnosis or treatment associated with criminal sexual assault or abuse.

D. HIV

A minor 12 years of age or older may consent to testing, treatment and counseling for HIV/AIDS.

If you have any questions about the information contained in this section, please contact your supervisor and consult with the Legal and Compliance Services Department, as necessary.

You have the right:

1. To be treated with dignity and respect and not be subject to verbal or other forms of abuse or neglect.

2. To receive treatment and other services without regard to race, color, religious affiliation, national origin, HIV status, physical or mental disability, age, sex including pregnancy, sexual orientation, gender identity, marital status, veteran status, family medical history and genetic information, or any other discriminatory factor and to have disabilities accommodated as required by law.

3. To provide services in the least restrictive setting.

4. To know that your confidential information will be safeguarded and will not be disclosed outside the agency without your written consent except as allowed by law and as described in our Notice of Privacy Practices.

5. To participate in the development of and have access to an individualized service plan and to review of your service plan at least once every 6 months, or otherwise as appropriate.

7. To refuse services and/or treatment and be informed of any consequences of such refusal, including consequences associated with refusing services mandated by court order.

8. To participate in or reuse to participate in research without compromising your access to treatment.

9. To have your rights explained to you in a language you understand and to have interpreter or use of communication technology where a communication barrier exists.

10. To have access to your record and request that inaccuracies be corroded.

11. To voice concerns or suggest changes in services and/or staff without being subject to threat, discrimination or interruption in services.

12. To exercise your rights and not have services terminated, suspended or restricted for exercising those rights.

13. To be notified of any client rights restriction(s) and to have your parent or guardian notified as well if applicable.

14. To be free from physical restraint/seclusion, unless such restraint is being used in an emergency or crisis situation to keep you from causing physical harm to yourself or others.

15. To file a complaint or grievance or to appeal decisions related to your services following the Agency’s Grievance Procedure.

16. To contact the Guardianship and Advocacy Commission, Equip for Equality, DCFS, DHS, OIG or DOC or their designee(s) to ask questions about your rights.  The contact information for these agencies is below.

17. To be referred to another provider at your request.

You have the responsibility:

1. To provide accurate and complete information regarding eligibility for services and if required for the services provided, medications and history of medical or psychiatric treatment.

2. To respect the rights of those providing services.

3. To respect the rights of other clients receiving services, and their propriety.

4. To keep information shared in therapeutic groups private and confidential and not disclose the names or other information about other clients receiving services.

5. To keep scheduled appointment and give reasonable notice if you cannot keep an appointment.

6. To keep current on paying any applicable fees.

7. To comply with safety rules and report safety risks.

8. To participate in your care by following mutually agreed upon treatment plans.

Purpose

The purpose of this disclosure of information is for treatment, payment and care coordination including, sharing my information to better integrate my treatment and coordinate other social supports I may need (such as housing, employment, food and other public assistance). 

If other purpose, please specify: Client location in case of medical emergency

This disclosure of information will be limited to that information which is necessary to carry out the purpose indicated herein.

Revocation

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to my worker/case manager and/or the Director of the Program at the Program site.  However, I understand that I cannot revoke this authorization to the extent that action has already been taken in reliance on the authorization. 

Conditions

I further understand that Catholic Charities of the Archdiocese of Chicago will not condition my treatment on whether I give authorization for the requested disclosure.  However, the consequences of my refusal to consent to this sharing of information, if any, are:  MAY HINDER SERVICES RENDERED

[Insert an explanation of the consequences, if any, of not signing this authorization, which will depend on the services being provided].

Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.  

Redisclosure

State and Federal law prohibit the person or organization to whom disclosure is made from making any further disclosure of this information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2 or the Illinois Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110/1 et seq.). 

Notice to Recipient of Substance Use Disorder Records specifically:      This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. Part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (See § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65.

I understand that I have the right to inspect and copy the information to be disclosed. I will be given a copy of this authorization for my records.

Purpose

The purpose of this disclosure of information is for treatment, payment and care coordination including, sharing my information to better integrate my treatment and coordinate other social supports I may need (such as housing, employment, food and other public assistance). 

If other purpose, please specify: That client is applying for rental assistance; verify amount owed; application status; assistance check

This disclosure of information will be limited to that information which is necessary to carry out the purpose indicated herein.

Revocation

I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to my worker/case manager and/or the Director of the Program at the Program site.  However, I understand that I cannot revoke this authorization to the extent that action has already been taken in reliance on the authorization. 

Conditions

I further understand that Catholic Charities of the Archdiocese of Chicago will not condition my treatment on whether I give authorization for the requested disclosure.  However, the consequences of my refusal to consent to this sharing of information, if any, are:  MAY HINDER SERVICES RENDERED

[Insert an explanation of the consequences, if any, of not signing this authorization, which will depend on the services being provided].

Form of Disclosure

Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with applicable law, including, but not limited to, verbally, in paper format or electronically.  

Redisclosure

State and Federal law prohibit the person or organization to whom disclosure is made from making any further disclosure of this information unless further disclosure is expressly permitted by the written authorization of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2 or the Illinois Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110/1 et seq.). 

Notice to Recipient of Substance Use Disorder Records specifically:      This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. Part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (See § 2.31). The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65.

I certify that the information presented in this application is correct and complete to the best of my knowledge.

I certify that I have not already been provided rental or utility assistance, through a LCRA provider or any other program, that covers the costs requested in this application.

As a person or entity receiving LCRA assistance, I agree to repay assistance that is determined to be duplicative. By signing below, this constitutes an agreement with Lake County in compliance with Lake County’s Duplication of Benefits policy.

I further understand(s) that providing false representations herein constitutes an act of fraud.