• Prevention Application

  • The prevention program can pay up to three months of past due rent, first month and deposit, or past due utility payments. 

    Applications are only accepted for those who are below 200% of 2026 Federal Poverty Guidelines and have a documented housing crisis within the past 30 days.

  • Did you complete the pre-screening with United Way 211?
  • All Washington County applications are required to complete the pre-screen verification process.  Please contact United Way 211 at 651.291.0211.

  • Documentation is needed to determine eligibility. Failure to provide documentation could delay your application, please be prepared to upload documents below.

    • Residency-You must provide proof of your residency. Documents may include: rental lease, utility bill, shelter form (from landlord)
    • Income-You must provide proof of your total household income for all working adults for the past 30-60 days. Documents may include: paystubs, benefit statements, etc.
    • Proof of Crisis (Rental Assistance)-If your household is requesting rental assistance, you must include the full contact information for your landlord and attach proof of crisis. Documents may include: intent to evict notice, court documents, notice to vacate, etc.
    • Proof of Crisis (Utilities)-If your household is requesting financial assistance to pay past due utilities, you must include your history of past due balance and your most recent statement.
  • Personal Information

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Please contact me by:
  • Do you want an interpreter?
  • *Please complete to the best of your ability. All information is voluntary; however, we collect this information for funding purposes and to best serve your family.

  • Are you a US Military Veteran?
  • Are you a US Citizen?
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  • Household Information

  • Children Information

  • Date of Birth
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  • Date of Birth
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  • Date of Birth
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  • Date of Birth
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  • Monthly Income

  • Monthly Income (Select all that apply)
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  • WHAT IS YOUR FINANCIAL NEED OR EMERGENCY?

  • Do you need assistance paying past due rent?*
  • Do you have a pending court date or have you been to court for eviction proceedings?
  • Pending or Past Court Date
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  • Do you need damage deposit and first month's rent?*
  • Move in Date*
     / /
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you need utility assistance? (choose all that apply)
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  • PLEASE ANSWER THE FOLLOWING QUESTIONS.

  • Have you applied for emergency assistance with your county in the past 12 months?*
  • Have you applied for financial assistance from any other agency in the past 12 months?*
  • Minnesota’s HMIS Data Privacy Notice

    We collect personal information about the people we serve in a computer system called Minnesota’s HMIS (Homeless Management Information System). Many social service agencies use this computer system, including street outreach, shelters, and housing programs.

    Why do we collect this information?

    • To help keep this program and others like it going. We are required to use HMIS.
    • So we know how many people we serve and the types of people we serve at our agency and in the state.
    • So we all understand what people need and can plan services to meet these needs.
      Who can see information that is in Minnesota’s HMIS?
    • People who work for this agency will use it to help provide services to you or your family.
    • Other agencies like this agency that provide services and have received permission from you to see your information. The agencies that participate in Minnesota’s HMIS may change from time to time. A copy of the current list of participating agencies is available upon request.
    • Auditors or funders who have legal rights to review the work of this agency, such as the U.S. Department of Housing and Urban Development and other state or local government entities.
    • Organizations that run, administer, and work on the system, such as the Institute for Community Alliances or Local System Administrators. When these organizations work on the system, they may see information about you.
    • People using HMIS information to do research and write reports, including, but not limited to, the Minnesota Department of Human Services (DHS). Your personally identifiable information will never appear in research reports.
    • The law says we have to report physical or sexual abuse of children and vulnerable adults. If we think there is abuse or neglect in your household, we will report it to Child or Adult Protection.
    • We may release your information to protect the health or safety of you or others as required by law.
    • Others as required by law, including officials with a valid subpoena, warrant, or court order.

    We will not release your information for any other use unless you permit us in writing.

    How is your privacy protected?

    • All users of data must sign an agreement to protect your privacy and comply with state and federal laws and policies before seeing any information.
    • The computer program used for this purpose has industry standard security protocols and is updated regularly to meet these security requirements.

    What are your rights?

    • If you do not want your name, social security number, or date of birth entered in HMIS, tell the intake worker. This agency will not refuse to help you for denying this. However, federal and state regulations may require limited data collection for funding purposes.
    • You have the right to request a copy of the Minnesota’s HMIS information about you.
    • You have the right to correct mistakes in HMIS information about you.
    • If you think this agency or Minnesota’s HMIS violated your privacy rights, you have the right to complain or appeal. Ask a staff person for a complaint and appeal form.
  • Date of Birth
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  • Your personal information will be collected in Minnesota’s HMIS and, with your consent, shared with other service providers/homeless agencies. If you do not give permission for this agency to share your information, no other agency in the network will have access to it.

    Why share your information?

    • Sharing reduces the amount of time you have to spend answering basic questions about your situation.
    • Sharing allows agencies to focus on meeting your unique needs more quickly.
    • Sharing makes it easier for multiple agencies to coordinate housing and services for you and your family.

    What information might be shared?

    • Family/Household information
    • Name, birthdate, Social Security Number
    • Gender, race, ethnicity
    • Reasons for seeking services
    • Living situation and housing history
    • Services you receive
    • If you are homeless or not
    • Your income and income sources
    • Public benefits you receive
    • History of domestic violence
    • Educational background
    • Employment information
    • Military history
    • Health information, including physical health, HIV, behavioral health
  • Choose one option:*
  • When you sign this form, it shows that you understand the following.

    • We will not deny you help if you do not want us to share your personal information. At the same time, sharing data does not guarantee that you will receive assistance.
    • If you permit us to share your information, this consent is valid until canceled by you.
    • If you permit us to share your information, you may change your mind and cancel this consent at any time. If you cancel this consent, your information will no longer be shared from that date forward
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  • SOLID GROUND NOTICE OF PRIVACY PRACTICES
    (HIPAA AND MINNESOTA LAW) AND CLIENT PRIVACY STATEMENT

    This Notice is effective April 14, 2003, and governs our privacy practices on and after that date.

    This Notice describes how your medical information may be used and disclosed and how you can get access to this information.  Please review it carefully.

    Federal and state privacy and medical records laws protect your rights as a client of Solid Ground.  This notice applies to your current contact with Solid Ground and all future contacts, whether the contact is in person, by telephone, or by mail.

    Solid Ground and affiliated businesses are required to protect the privacy of your Protected Health Information (PHI).  We are also required by the Health Insurance Portability and Accountability Act (HIPAA) to provide you with a notice of our legal duties and privacy practices with respect to PHI.  The terms we, our, and us refer to Solid Ground, and the terms you and your refer to our clients.

    NOTICE INFORMATION

    This Notice of Privacy Practices describes how we may use and disclose your PHI to carry out treatment, payment, and health care operations and for other purposes that are specified by law.

    We reserve the right to change this Notice.  The changes will apply for PHI we already have about you and PHI we receive about you in the future.  We will provide an updated Notice to you when you request one. If you have questions about this Notice, our privacy practices, or the Solid Ground services this Notice applies to, please contact us at:

    Solid Ground
    3521 Century Avenue N
    White Bear Lake, MN  55110
    651-773-8401

    PROTECTED HEALTH INFORMATION

    Protected Health Information (PHI) is:

    1. Information about your physical or mental health, related health care services, or payment for health care services.
    2. Information that is provided by you, created by us, or shared with us by related organizations.
    3. Information that identifies you or could be used to identify you, such as demographic information, address and phone number, social security number, age, date of birth, dependents, and health history.

    HOW SOLID GROUND PROTECTS YOUR PHI

    Except as described in this Notice or specified by law, we will not use or disclose your PHI.  We will use reasonable efforts to request, use, and disclose the minimum amount of PHI necessary.

    Whenever possible, we will de-identify or encrypt your personal information so that you cannot be personally identified.  We may put physical, electronic, and procedural safeguards in place to protect your PHI and comply with federal and state laws.

    YOUR RIGHTS

    You have the following rights with respect to your PHI.

    Obtain a copy of this Notice.  You may obtain a copy of the Notice at any time.  Even if you have agreed to receive the Notice electronically, you are still entitled to a paper copy.

    Request restrictions.  You may ask us not to use or disclose any part of your PHI.  Your request must be in writing and include what restriction(s) you want and to whom you want the restriction(s) to apply.  We will review and grant reasonable requests, but we are not required to agree to any restrictions.

    Inspect and copy.  You have the right to inspect and get a copy of your PHI for as long as we maintain the information.  You must put your request in writing.  We may charge you for the costs of copying, mailing, or other supplies that are necessary to grant your request.

    We do have the right to deny your request to inspect and copy.  If you are denied access, you may ask us to review the denial.

    Request amendment.  If you feel that your PHI is incomplete or incorrect, you may ask us to amend it.  You may ask for an amendment for as long as we maintain the information.  Your request must be in writing, and you must include a reason that supports your request.

    In certain cases, we may deny your request.  If we deny your request for amendment, you have the right to file a statement of disagreement with our decision.

    Receive a list (an accounting) of disclosures. You have the right to receive a list of the disclosures (an accounting) that we have made of your PHI on or after April 14, 2003

    The list will not include disclosures that we are not required to track, such as disclosures for the purposes of treatment, payment, or health care operations: disclosures which you have authorized us to make; disclosures made directly to you or to friends or family members involved in your care; or disclosures for notification purposes.

    Your right to receive a list of disclosures may also be subject to other exceptions, restrictions, and limitations.

    Your request for an accounting must be made in writing and state the time period for which you would like us to list the disclosures. We will not include disclosures made more than six years prior to the date of your request, or disclosures made prior to April 14, 2003.

    You will not be charged for the first disclosure list that you request, but you may be charged for additional lists provided within the same 12-month period as the first.

    Request confidential communication.  You may ask us to communicate with you using alternative means or alternative locations. For example, you may ask us to contact you about medical records only in writing or at a different address than the one in your file. Your request must be made in writing and state how and when you would like to be contacted.

    You do not have to tell us why you are making the request, but we may require you to make special arrangements for payment or other communications.

    We will review and grant reasonable requests, but we are not required to agree to any restrictions.

    Note: Special Rules for Psychotherapy Notes. Only psychotherapy notes collected by a psychotherapist during a counseling session are considered PHI. If those notes are kept separate from a client’s medical records, HIPAA requires that they be treated with higher standards or protection than other PHI.

    It is not Solid Ground's practice to keep psychotherapy notes as defined by HIPAA, or to keep any client notes separate from the client’s file.

  • WHEN SOLID GROUND MAY USE AND DISCLOSE PHI

    Common reasons for our use and disclosure of PHI include:

    Treatment. To provide, coordinate, or manage health care and related services for you to make sure you are receiving appropriate and effective care.

    For example, we may contact you to provide appointment reminders, information about treatment alternatives, or to refer you to other health-related benefits and services that may be of interest to you. Or we might contact another health care provider or third party to share information or consult with them about the services we are providing to you.

    Payment. To obtain payment or reimbursement for services provided to you. For example, we may need to disclose PHI to determine eligibility for treatment or claims payment.

    Health Care Operations. To assist in carrying out administrative, financial, legal, and quality improvement activities necessary to run our business and to support the core functions of treatment and payment.

    Business Associates. Our business associates perform some health care administration and operation activities for us. Examples of our business associates include our claims administrator and utilization review service provider. We may disclose PHI to our business associates so that they can perform the job we have asked them to do.

    We require our business associates to sign agreements that limit how they use and disclose PHI. We require them to protect PHI and to follow our privacy practices.

    Health Plan Sponsor. We may disclose PHI to a group health plan administrator, which may, in turn, disclose such PHI to the group health plan sponsor, solely for purposes of administering benefits provided by Solid Ground.

    Individuals involved in your care or payment for your care. We may disclose your PHI to a family member, other relative, close personal friend, or any person you identify, who is, based on your judgment, believed to be involved in your care or in payment related to your care.

    As required by law. We must disclose PHI about you when required to do so by law.

    Less common reasons for our use and disclosure of PHI include:

    Legal proceedings. We may disclose PHI for a judicial or administrative proceeding in response to a court order, written notice, or protective order. Solid Ground will not release PHI pursuant to a subpoena.

    Coroners, funeral directors, and organ donations. We may disclose PHI to coroners, medical examiners, or funeral directors to enable them to perform duties authorized by law. PHI may also be used and disclosed for organ, eye, or tissue donations.

    To avert serious threat to public health or safety. We may disclose PHI to avoid a serious and imminent threat to your health or safety or to the health or safety of others.

    Military or national security and intelligence activities. We may disclose PHI to armed forces personnel under certain circumstances and to authorized federal officials for national security and intelligence activities, including protective services for the President and other heads of state.

    Fundraising. We may disclose PHI for fundraising activities. You would be given the opportunity to ‘opt out’ of receiving such fundraising solicitations.

    Research. We may use PHI to assist us with internal research and program evaluation activities. We would get your written authorization before using your PHI. You would also be given the opportunity to ‘opt out’ of research activities.

    To provide reminders and benefits information to you. Disclosures may be used to verify your eligibility for health care are enrollment in various health plans and to assist us in coordinating benefits for those who have other health insurance or eligibility for government benefit programs.

    Worker’s compensation. We may disclose PHI to comply with worker’s compensation laws and other similarly legally established programs.

    Food and Drug Administration (FDA). We may disclose PHI to a person or company required by the FDA to report adverse events or product defects or problems, track products, enable product recalls, make repairs or replacements, monitor post-marketing as required.

    Public health. We may disclose PHI to a public health authority that is permitted by law to receive the information for public health activities. This disclosure might be necessary to prevent or control disease, injury, or disability. For example, we may disclose your PHI to the childhood immunization registry.

    Abuse or neglect. We may make disclosures to government authorities or social service agencies as required by law in the reporting of abuse, neglect, or domestic violence.

    Marketing. We do not anticipate use of PHI for marketing purposes. If we did so, we would need to get a signed authorization from you and would notify you of any possible payment made to Solid Ground.

    To government agencies for compliance purposes. We may use or disclose PHI to the Secretary of Health and Human Services to assist with a complaint investigation or compliance review.

    Correctional facility. We may use or disclose PHI, as authorized by law, if you are an inmate of a correctional facility.

    Law enforcement. We may disclose PHI to law enforcement officials for the purpose of identifying or locating a suspect, witness, or missing person, or to provide information about victims of crimes.

  • Your written permission

    We are required to get your written permission (authorization) before using or disclosing your PHI for purposes other than those provided above, or as otherwise permitted or required by law. If you do not want to authorize a specific request for disclosure, you may refuse to do so without fear of reprisal.

    You may withdraw your permission

    If you do provide your written authorization and then later want to withdraw it, you may do so in writing at any time. As soon as we receive your written revocation, we will stop using or disclosing the PHI specified in your original authorization, except to the extent that we have already used it based on your written permission.

    You may file a complaint

    If you believe your privacy rights have been violated, you can file a complaint with Solid Ground’s HIPAA Privacy Officer, or with the United States Department of Health and Human Services at:

    Medical Privacy Complaint Division Office for Civil Rights
    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, DC 20201
    1-800-368-1019

    Filing a complaint will in no way affect the care or services you receive from Solid Ground.

    DATA PRIVACY 

    Why do we ask for information?

    We ask for information from you to determine what service or help you need, develop a service plan with you, and give you the services you want.

    The information may also be used to determine your charges for services or for collection of payment from insurance companies or other payment sources.

    Do you have to give information to us?

    There is no law that says you must give us any information. However, if you choose to not give us some information, it can limit our ability to serve you well.

    What will happen if you do not answer the questions we ask?

    If you are here because of a court order, and you refuse to provide information, that refusal may be communicated to the court.

    Without certain information, we may not be able to tell who shoulc pay for your services.

    What privacy rights do minors have?

    If you are under 18, you may request that information about you be kept from your parents. You must give us your request in writing, describe the information, and tell us why you don’t want your parents to see it.

    If, after reviewing your request, Solid Ground staff believe that giving information to your parents is not in your best interest, we will not share the information. If Solid Ground staff believe this information could be safely shared with your parents, we will inform you of that decision.

    If you are 16, you may ask for mental health services without the consent of your parents, but you may have to pay for the services if you do not want your parents to know.

    Please sign this form.  Your signature shows that we have informed you of your privacy rights and that you are aware of the possible uses and disclosures of your protected health information.

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  • SOLID GROUND
    Participant Privacy Statement
    Tennessen Warning

  • There are laws under the Minnesota Government Data Practices Act which protect your rights as a participant of Solid Ground. This statement of rights applies to your current contact with Solid Ground as well as all future communications, whether the communication is in person, by telephone, or by mail.  If you have any questions about this statement or any of your rights as described, you may discuss them with the appropriate Solid Ground staff person. Specific information about how you can get copies of data, and other procedures are available upon request.

    DATA PRIVACY

    Why do we ask for information?
    We ask for information from you to determine what service or help you need, to develop a service plan with you, and to give you the services you want. 

    Must you give information, or can you refuse to provide information?
    No law says you must give us any information.  However, if you do not provide us with some information, it can limit our ability to serve you well or, in some cases, provide services.

    What will happen if you do not answer the questions we ask?
    If you receive some services because of a court order and refuse to provide information, that refusal may be communicated to the court.

    Who else may see the information you give us?
    Information we have about you may be shared with other agencies or individuals under the following circumstances:

    • If you consent to the sharing by signing a Release of Information form;
    • If a law states that we have to give information, including laws that require reporting child abuse or vulnerable adult abuse;
    • If there is a contract granting access, including the release of information to auditors and accrediting agencies;
    • To the staff of Solid Ground who need the data to perform their jobs;
    • To tell family members or other persons about conditions by acceptable medical practice;
    • Organizations responsible for paying for your services;
    • Responding to lawful subpoenas and court orders;
    • Child or adult protection teams;
    • If a program participant states an intention to harm themselves or another person seriously, a Solid Ground staff person may have a legal obligation to contact authorities or warn the intended victim;
    • If a child is enrolled in any of our programs, the non-custodial parent will generally be provided information about the child’s participation in the program when requested.
    • Information to the following agencies for data collection purposes:  Amherst H. Wilder Foundation, Wilder Research Center, Minnesota Department of Human Services, Greater Twin Cities United Way, the U.S. Department of Housing and Urban Development, Ramsey County, Washington County, and Minnesota Housing.  

    YOU HAVE THE RIGHT TO REQUEST COPIES OF INFORMATION WE HAVE ABOUT YOU.

    You may ask if we have any information about you.

    If we have information about you, you may ask for copies.  You may have to pay for these copies.

    You may give others permission to see and have copies of private data about you.

    If the information is unclear, you may ask to have it explained to you.

    If you feel the information, we have about you is inaccurate or incomplete, you may file a letter of disagreement with Solid Ground.

    I have read the above, or it has been read to me, and I understand my data privacy rights as they have been explained to me.

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  • This document can be made available in alternative formats, such as large print, Braille, or audiotape, by calling 651-773-8401.  For TTY communication, contact the Minnesota Relay Service at 711 or 1-800-627-3529 and ask them to place a call at 651-773-8401.

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