Amirah's Rapid ReHousing Application
Applicant's Information
Applicant's Full Legal Name
*
First Name
Last Name
Applicant's Preferred Name
Amirah's Rapid ReHousing Program is for female-identifying individuals. Does the applicant identify as female?
*
Yes
No
Which preferred pronouns does the applicant use?
she/her
he/him
they/them
Other
Amirah's Rapid ReHousing Program is for individuals who are 18 years of age or older. Is the applicant over the age of 18?
*
Yes
No
Applicant's Date of Birth
*
-
Month
-
Day
Year
Date
Applicant's Social Security Number (###-##-####)
*
Applicant's Phone Number
*
Please enter a valid phone number.
Please check off all that apply regarding the phone number applicant has provided.
*
It is safe for Amirah to call applicant's phone number and identify that the call is coming from Amirah.
It is safe for Amirah to leave a message/voicemail on this phone number and identify that the call is from Amirah.
It is safe for Amirah to text message this phone number and identify that the communication is from Amirah.
It is NOT safe to contact this phone number and it is NOT safe for Amirah to identify themselves on this number.
Applicant's Email
*
example@example.com
Is it safe for Amirah to email the applicant's provided email?
*
Yes
No
One of the criteria for this program is that the applicant currently lives in Massachusetts. Is the applicant currently living in Massachusetts?
*
Yes
No
Applicant's Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Amirah's Rapid ReHousing Program is for single individuals, meaning participants will be living alone during their participation in the program and will not be living with anyone else including but not limited to: partners, dependents, family, friends, and roommates. Does the applicant understand and agree to this?
*
Yes
No
Please provide information for who referred the applicant including individual's name, agency, contact phone number, and contact email. If applicant is self-referring, please write "self-referral."
*
Emergency Contact Information
Participants in Amirah's Rapid ReHousing Program are required to have an emergency contact and provide contact information to Amirah for their emergency contact. Participants are also required to have an active Release of Information on file authorizing Amirah to contact their emergency contact. Please note Amirah only contacts emergency contacts when absolutely necessary to do so. Does the applicant agree to Amirah's requirements regarding emergency contacts?
*
Yes
No
Emergency Contact's Name
*
First Name
Last Name
What is the emergency contact's relationship to the applicant?
*
Emergency Contact's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact's Phone Number
*
Please enter a valid phone number.
Emergency Contact's Email
example@example.com
Homelessness Status
PLEASE READ THIS SECTION CAREFULLY. Amirah's Rapid ReHousing Program is for individuals experiencing homelessness/housing instability, but who DO NOT meet the United States' Department of Housing and Urban Development's (HUD's) definition of chronic homelessness. HUD's definition of chronic homelessness is explained further in this section to help applicants determine if they meet this this definition or not.
Is the applicant currently experiencing homelessness/housing instability?
*
Yes
No
Does the applicant have any of the following disabling condition(s) (Please check all answers that apply).
*
A diagnosable substance use disorder
A serious mental illness
A developmental disability
A chronic physical illness or disability, including the co-occurrence of two or more of these conditions
Applicant does NOT have a disabling condition
Has the applicant been continuously homeless for a year or more? HUD defines “homelessness” as “a person sleeping in a place not meant for human habitation (e.g. living on the streets) OR living in a homeless emergency shelter.
*
Yes
No
Has the applicant had four (4) episodes of homelessness in the last three (3) years?HUD defines “homelessness” as “a person sleeping in a place not meant for human habitation (e.g. living on the streets) OR living in a homeless emergency shelter.
*
Yes
No
Please read this carefully. If the applicant has one of the above listed disabling conditions AND has checked off yes to either of the above questions: "Has the applicant been continuously homeless for a year or more? HUD defines “homelessness” as “a person sleeping in a place not meant for human habitation (e.g. living on the streets) OR living in a homeless emergency shelter." or "Has the applicant had four (4) episodes of homelessness in the last three (3) years? HUD defines “homelessness” as “a person sleeping in a place not meant for human habitation (e.g. living on the streets) OR living in a homeless emergency shelter." then she would meet HUD's definition of chronic homelessness, and would NOT be eligible for Amirah's Rapid ReHousing Program. She will be screened out. Programs like Permanent Supportive Housing are designed for individuals who meet HUD's definition of chronic homelessness.
Applicants who ARE screened in for Amirah's Rapid ReHousing Program are required to provide a verification of homelessness from a service provider or law enforcement officer in order to be placed on the applicant waitlist. Participants are also required to have an active Release of Information on file authorizing Amirah to contact their individual/agency that will provide them with a homelessness verification. Does the applicant understand and agree to Amirah's requirements around homeless verification and having an active Release of Information on file?
*
Yes
No
If the applicant has a homelessness verification that they are able to upload immediately, they may do so here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
HOUSING HISTORY TIMELINE FOR THE LAST 36 months (3 years)
Please begin with the applicant's current location and then provide the rest of her history in reverse chronological order.
Where is the applicant currently living?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When did the applicant first start living at her current location?
*
-
Month
-
Day
Year
Date
What type of setting is the location that she is currently staying in?
*
Her own home
A friend or family member's home
A place not meant for human habitation (ie. car, street, safe haven)
A shelter
Hotel/Motel
Alcohol/Substance Use Treatment Program
Sober House
Correctional Facility
Residential Program
A trafficker and/or abuser's home
Other
If her current location is a shelter, alcohol/substance use treatment program, sober house, correctional facility, residential program, or any other type of program, please provide the name of that program. If she did not live in one of these types of settings, write "n/a."
*
Second Most Recent Location
Where did she live IMMEDIATELY BEFORE where she is currently staying? If she did not live in a different location in the last 36 months, write "n/a"
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When did she start living at that location? If she did not live somewhere else, put in "n/a."
*
What type of setting was that location?
*
Her own home
A friend or family member's home
A place not meant for human habitation (ie. car, street, safe haven)
A shelter
Hotel/Motel
Alcohol/Substance Use Treatment Program
Sober House
Correctional Facility
Residential Program
A trafficker and/or abuser's home
She did not live anywhere else in the last 36 months.
Other
If that location was a shelter, alcohol/substance use treatment program, sober house, correctional facility, residential program, or any other type of program, please provide the name of that program. Write "n/a" if this does not apply.
*
Third Most Recent Location
Where did she live before the second to last location? If she did not live somewhere different in the last 36 months, write "n/a"
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of setting was this location?
*
Her own home
A friend or family member's home
A place not meant for human habitation (ie. car, street, safe haven)
A shelter
Hotel/Motel
Alcohol/Substance Use Treatment Program
Sober House
Correctional Facility
Residential Program
A trafficker and/or abuser's home
She did not live anywhere else in the last 36 months.
Other
If that location was a shelter, alcohol/substance use treatment program, sober house, correctional facility, residential program, or any other type of program, please provide the name of that program. Write "n/a" if this does not apply.
*
Fourth Most Recent Location
Where did she live before the third to last location? If she did not live somewhere different in the last 36 months, write "n/a"
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of setting was this location?
*
Her own home
A friend or family member's home
A place not meant for human habitation (ie. car, street, safe haven)
A shelter
Hotel/Motel
Alcohol/Substance Use Treatment Program
Sober House
Correctional Facility
Residential Program
A trafficker and/or abuser's home
She did not live anywhere else in the last 36 months.
Other
If that location was a shelter, alcohol/substance use treatment program, sober house, correctional facility, residential program, or any other type of program, please provide the name of that program. Write "n/a" if this does not apply.
*
Fifth Most Recent Location
Where did she live before the fourth to last location? If she did not live somewhere different in the last 36 months, write "n/a"
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of setting was this location?
*
Her own home
A friend or family member's home
A place not meant for human habitation (ie. car, street, safe haven)
A shelter
Hotel/Motel
Alcohol/Substance Use Treatment Program
Sober House
Correctional Facility
Residential Program
A trafficker and/or abuser's home
She did not live anywhere else in the last 36 months.
Other
If that location was a shelter, alcohol/substance use treatment program, sober house, correctional facility, residential program, or any other type of program, please provide the name of that program. Write "n/a" if this does not apply
*
Additional Housing History
If she has lived in any additional places in the last 36 months, please put the same information as above (address, when she began living there, type of setting, program name, etc.). If she did not live anywhere else, please write "n/a"
*
Sex Trafficking Screening Tool
Amirah's Rapid ReHousing Program is for individuals who have experienced victimization from sex trafficking. This screening tool ask a series of 9 "yes"/"no" questions to help determine if the applicant has experienced victimization from sex trafficking.
Trigger Activation Warning
The screening questions are intentionally "yes/no" questions and do not require applicants to go into detail, but we acknowledge that these questions may still bring up some uncomfortable and/or distressing thoughts and feelings for someone reading and answering them. We appreciate the courage it takes to open up and take a step forward in this part of someone's journey.
1) Has the applicant participated in one or more of the following sex acts: stripping and/or lap dancing, escort services, prostitution, intercourse and/or oral sex for a fee, phone sex, and/or pornography (including but not limited to: web cam modeling, being in sexual videos, and/or posing for sexual photos)?
*
Yes
No
Declining to answer
Do not know
2) Has the applicant ever participated in a sex act in exchange for one or more of the following: food, a place to stay, transportation, money, safety and/or protection, gifts and/or favors, or substances?
*
Yes
No
Declining to answer
Do not know
3) Has someone other than the applicant ever received money, substances, or something else of value from a sex act the applicant has participated in?
*
Yes
No
Declining to answer
Do not know
4) Has someone ever published pornography of the applicant and without her consent and without her knowledge at the time it happened? This can include video or audio documentation of a sex act that was distributed beyond the people involved in the sex act. Sometimes this is referred to as “revenge porn.”
*
Yes
No
Declining to answer
Do not know
5) Has the applicant ever participated in a sex act after being promised a better life, a place to live, and/or after being offered a job that didn’t really exist? (Examples of the job that didn't really exit may be model, nurse, and/or nanny).
*
Yes
No
Declining to answer
Do not know
6) Has the applicant ever participated in a sex act after being tricked into entering a manipulative romantic relationship and/or friendship?
*
Yes
No
Declining to answer
Do not know
7) Has the applicant ever been forced to participate in a sex act through threats of, or actual experiences of physical violence, sexual assault, torture, starvation, imprisonment, and/or psychological abuse?
*
Yes
No
Declining to answer
Do not know
8) Has the applicant ever participated in a sex act because she received any of the following threats: serious harm would happen to her or people she cared about such as her family; she would be deported and/or arrested; and/or she would be "outed” to her family and/or community?
*
Yes
No
Declining to answer
Do not know
9) Has the applicant ever participated in a sex act because she was told she had a debt that she needed to repay?
*
Yes
No
Declining to answer
Do not know
Income Guidelines
HUD sets forth annual income guidelines for participants in Amirah's Rapid ReHousing Program where participants should not exceed the 30% limit for 1 person. Below are the current income guidelines set forth by HUD.
Participants must not exceed the 30% income limit for 1 person set forth by HUD for Amirah's Rapid ReHousing Program. Does the applicant meet these income limit guidelines?
*
Yes
No
Required Documents
If an applicant is screened into Amirah's Rapid ReHousing Program, she is required to provide copies of her personal documents to Amirah prior to moving into the program. There may be additional documents that applicants will provide copies of to Amirah if applicable. Applicants are encouraged to work with their referring partners on the process of obtaining any missing personal documents.
Please check off all documents that applicant has in her possession that she can provide copies of to Amirah.
*
A valid, government-issued photo ID (ex. front & back of state ID, front & back of state driver's license, passport)
A SIGNED social security card
Proof of US residency/citizenship (ie. birth certificate)
(If applicable) health insurance card(s)
(if applicable) non-cash benefits (ex. SNAP card)
(If applicable) income verifications (ex. paystubs, SSI verification, SSDI verification, unemployment benefits verification, VA benefits verification, EAEDC verification, etc.).
Applicant does not have any of these documents currently in her possession
If applicant has a copy of her valid, government-issued photo ID, she may upload it here. If she is uploading a state ID or driver's license, she should upload both the front and back of the card.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If applicant has a copy of her signed social security card, she may upload it here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If applicant has a copy of her proof of citizenship (ie. birth certificate), she may upload it here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If applicant has a copy/copies of her health insurance card(s), she may upload it/them here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If applicant has a copy of her non-cash benefits (ex. SNAP card), she may upload it here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If applicant is receiving any form(s) of income, she may upload her income verifications here.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
End of Application/Next Steps
Within 3 business days of receiving this application, an Amirah team member will reach out to the applicant to inform them about the status of their application and any next steps.
If the applicant enters into the Amirah Rapid ReHousing Program, she understands that the Program is an independent, rental assistance program and participation in the program is for up to 48 months.
*
Yes
No
If the applicant enters into the Amirah Rapid ReHousing Program, she understands that she will be paying up to 30% of her monthly income (no more than $600) towards her monthly rent. She also understands that she will provide updated income verifications to Amirah prior to a new sublease start date to help determine her rent amount.
*
Yes
No
If the applicant enters into the Amirah Rapid ReHousing Program, she understands that upon entering the program, she will be responsible for putting the apartment utilities account(s) in her name and that she will be responsible to pay for utilities if this is a condition of her sublease agreement.
*
Yes
No
If the applicant enters into the Amirah Rapid ReHousing Program, she understands that Amirah holds the master leases to each apartment and that she will sign ongoing subleases every 1-3 months with Amirah. She agrees to follow the conditions listed within her sublease agreements. Amirah will hold the major lease for the apartment and participants will sign subleases with Amirah. Subleases will typically be valid for 1-3 month terms at a time.
*
Yes
No
If the applicant enters into the Amirah Rapid ReHousing Program, she understands that she will be required to engage in budgeting and financial literacy.
*
Yes
No
If the applicant enters into the Amirah Rapid ReHousing Program, she understands that she has opportunities to engage in optional services that Amirah provides. These services include but are not limited to: case management resource referrals, life coaching, affordable housing search existence, career and/or educational exploration/planning support, group work, and community events.
*
Yes
No
If the applicant enters into the Amirah Rapid ReHousing Program, she agrees to sign a Release of Information authorizing Amirah to contact the local crisis team should a mental health emergency arise. This Release of Information must remain active on file.
*
Yes
No
The applicant may include any additional information she would like to share with Amirah. This is optional.
Applicant's Signature
Submit
Should be Empty: