Emaus Application

Name

First NameLast Name

Email

example@example.com

I,{name}, hereby authorize full communication regarding my progress within Third Party Administrator (TPA) service providers, including but not limited to: my demographic information, justice system involvement, service assessments, services information, and my program outcomes on a need to know basis between the following agencies:

Los Angeles County (JCOD)
Amity Foundation TPA Project
TPA Funded Community-Based Program (CBP) of My Enrollment
Peregrinos de Emaus

The purpose of this disclosure is to coordinate service provision and all data associated with CFCI funding.

I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and HIPAA and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

Expiration if mandated into TPA community services-This consent will expire automatically when there has been a formal and effective termination of services by the program provider.

Expiration if TPA services are voluntary- If I sign up for TPA services without legal mandates to do so, this release will expire thirty days after I complete the TPA funded program and/or services, successfully or unsuccessfully. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it.

I also understand that recipients of any information disclosed in accordance with Part 2 of Title 42 CFR or HIPAA may re-disclose it only in connection with their official duties.

Organization Name: Peregrinos de Emaus

{typeA}

Participant Name (Client/Legal Guardian):{name}

Signature

If signed by an authorized person other than client, indicate relationship:

Name

First NameMiddle NameLast Name

Date of Birth*

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.

I, {name} agree to participate in the program from Los Angeles County called, "My First Place."

My First Place, is a program for the youth of Los Angeles County who are 18-26 years of age and are at risk of homelessness or housing insecurity.

I affirm that I or my family is experiencing any or all of the following:

-Homelessness

-Housing Insecurities

-At major risk of experiencing homelessness

-At major risk of experiencing housing insecurities

-Living in a car

-Living in a temporary space

-Will use the grant money for a primary place of living

Signature

Date

Name*

First NameMiddle NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Last 4 of your SSN#*

Age Group:*

Are You Homeless:*

If yes, please write cross streets of where you are living.

Race:*

If Other (Please Specify):

Ethnicity:*

Gender:*

Veteran Status:*

Where you Referred?*

If Yes, Please Specify:

How did you hear about us?*

If other, please specify:

Services I May Need:*

Housing Services (Emergency Housing)Basic Necessities (Food, clothing, toiletries)Case ManagementMental Health Services (referral to Therapist)Substance Use Services (referral to Therapist)Transportation (Uber, taxi cab)

Please upload any lease or invoice that you have agreed to for funding.

Browse Files

Please upload a picture of your photo ID.*

Browse Files

Administrator Code:

For Administrators Only

Release of Information

Emaus Affidavit

Emaus Intake Form