Amirah's Rapid ReHousing Application

Amirah's Rapid Re-Housing Application

Please note the waitlist to enter this program is currently up to 24 months.
Other organizations that you may reach out to include but are not limite to:
- The National Human Trafficking Hotline.
  - Telephone: 1-888-373-7888
  - TTY: 711
  - Text* 233733
- The National Trafficking Sheltered Alliance. The link to their website is here.
- SafeLink, a 24/7 domestic violence hotline in Massachusetts.
  - 1-877-785-2020.
- The Suicide and Crisis Hotline
  - 988
- The Massachusetts Behavioral Health Help Line
  - 1-833-773-2445
If you are experiencing a medical or mental health emergency, please call 911 or go to the nearest emergency room.
Amirah's Rapid ReHousing Program serves single (having no dependents), female-identifying adults who are located in Massachusetts, who are experiencing homelessness (but who do not meet HUD's definition of chronic homelessness; see definition here), and who have experienced victimization via sex trafficking.
Applicant's Information
Applicant's Full Legal Name*

First NameLast Name
Applicant's Preferred Name
Amirah's Rapid ReHousing Program is for female-identifying individuals. Does the applicant identify as female?*

YesNo
Which preferred pronouns does the applicant use?

she/herhe/himthey/themOther
How does applicant describe their sexual identity? (Select all that apply)*

Heterosexual/StraightHomosexual/Gay/LesbianBisexualAsexualPansexualApplicant doesn't knowApplicant declines to answerOther
Amirah's Rapid ReHousing Program is for individuals who are 18 years of age or older. Is the applicant over the age of 18?*

YesNo
Applicant's Date of Birth*

MonthDayYear
Date
What ethnicity does the applicant identify as?*

Hispanic/LatinxNon-Hispanic/LatinxApplicant doesn't knowApplicant declines to answer
What race(s) does the applicant identify as? Check all that apply*

American Indian or Alaska NativeAsianBlack or African AmericanMiddle Eastern or North AfricanNative Hawaiian or Other Pacific IslanderWhiteApplicant does not knowApplicant declines to answer
What is applicant's marital/relationship status?*

SinglePartneredMarriedDivorcedSeparatedWidowed
What is applicant's immigration status?*

Asylum SeekerCitizenImmigrantRefugee
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?*

YesNo
One of the criteria for this program is that the applicant currently lives in Massachusetts. Is the applicant currently living in Massachusetts?*

YesNo
Applicant's Mailing Address*

Street Address

Street Address Line 2

CityState / 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?*

YesNo
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?*

YesNo
Emergency Contact's Name*

First NameLast Name
What is the emergency contact's relationship to the applicant?*
Emergency Contact's Address

Street Address

Street Address Line 2

CityState / 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 definition or not. The definition can be found here.
Is the applicant currently experiencing homelessness/housing instability?*

YesNo
Does the applicant have any of the following disabling condition(s) (Please check all answers that apply).*

A diagnosable substance use disorderA serious mental illnessA developmental disabilityA chronic physical illness or disability, including the co-occurrence of two or more of these conditionsApplicant 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. (If the answer is yes AND the applicant has a disabling condition, they cannot be screened in for this program).*

YesNo
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. (If the answer is yes AND the applicant has a disabling condition, they cannot be screened in for this program).*

YesNo
Please read this carefully. If the applicant has one or more 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?*

YesNo
If the applicant has a homelessness verification that they are able to upload immediately, they may do so here.

Cancelof
HOUSING HISTORY

We are required to collect applicants' housing history for the last 36 months (3 years) to determine if they meet HUD's definition of chronic homelessness
Where is the applicant currently living?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What type of community is the applicant currently living in?*

RuralSuburbanUrban
When did the applicant first start living at her current location?*

MonthDayYear
Date
What type of setting is the location that she is currently staying in?*

Her own homeA friend or family member's homeA place not meant for human habitation (ie. car, street, safe haven)A shelterHotel/MotelAlcohol/Substance Use Treatment ProgramSober HouseCorrectional FacilityResidential ProgramA trafficker and/or abuser's homeOther
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

CityState / Province

Postal / Zip Code
When did she start living at that location? If she did not live somewhere else, put in "n/a."*
When did she stop living at that location? If she did not live somewhere else, put in "n/a."*
What type of setting was that location?*

Her own homeA friend or family member's homeA place not meant for human habitation (ie. car, street, safe haven)A shelterHotel/MotelAlcohol/Substance Use Treatment ProgramSober HouseCorrectional FacilityResidential ProgramA trafficker and/or abuser's homeShe 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

CityState / Province

Postal / Zip Code
When did she start living at that location? If she did not live somewhere else, put in "n/a."*
When did she stop living at that location? If she did not live somewhere else, put in "n/a."*
What type of setting was this location?*

Her own homeA friend or family member's homeA place not meant for human habitation (ie. car, street, safe haven)A shelterHotel/MotelAlcohol/Substance Use Treatment ProgramSober HouseCorrectional FacilityResidential ProgramA trafficker and/or abuser's homeShe 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

CityState / Province

Postal / Zip Code
When did she start living at that location? If she did not live somewhere else, put in "n/a."*
When did she stop living at that location? If she did not live somewhere else, put in "n/a."*
What type of setting was this location?*

Her own homeA friend or family member's homeA place not meant for human habitation (ie. car, street, safe haven)A shelterHotel/MotelAlcohol/Substance Use Treatment ProgramSober HouseCorrectional FacilityResidential ProgramA trafficker and/or abuser's homeShe 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

CityState / Province

Postal / Zip Code
When did she start living at that location? If she did not live somewhere else, put in "n/a."*
When did she stop living at that location? If she did not live somewhere else, put in "n/a."*
What type of setting was this location?*

Her own homeA friend or family member's homeA place not meant for human habitation (ie. car, street, safe haven)A shelterHotel/MotelAlcohol/Substance Use Treatment ProgramSober HouseCorrectional FacilityResidential ProgramA trafficker and/or abuser's homeShe 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"*
Trigger Activation Warning

The next series of questions will ask about sex trafficking and other forms of victimization (domestic violence, sexual assault, and stalking). While these questions do not require an applicant to go into details about her experience(s), 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.
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.
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)?*

YesNoDeclining to answerDo 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?*

YesNoDeclining to answerDo 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?*

YesNoDeclining to answerDo 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.”*

YesNoDeclining to answerDo 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).*

YesNoDeclining to answerDo not know
6) Has the applicant ever participated in a sex act after being tricked into entering a manipulative romantic relationship and/or friendship?*

YesNoDeclining to answerDo 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?*

YesNoDeclining to answerDo 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?*

YesNoDeclining to answerDo 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?*

YesNoDeclining to answerDo not know
Incident Experiencing
Has the applicant experienced any of the following types of victimization? Check all that apply.*

Domestic ViolenceSexual AssaultStalkingApplicant did not experience any of these types of victimizationsApplicant does not knowApplicant declines to answer
If the applicant has experienced victimization via domestic violence, sexual assault,, and/or stalking what was her victimization status? Check all that apply.*

Applicant was the primary person who experienced one or more of these typs of victimizations.Applicant was the secondary person who experienced one or more of these types of victimization.Applicant did not experience any of these types of victimization.Applicant does not know.Applicant declines to answer.
If the applicant did experience victimization via domestic violence, sexual assault, and/or stalking, what is/was the abusive person's relationship(s) to the applicant? Check all that apply.*

Current or former spouse or intimate partnerOther family or household memberAcquaintanceCurrent or former dating relationship partnerStrangerTraffickerBuyerRelationship unknownApplicant did not experience any of these types of victimizationsApplicant does not knowApplicant declines to answer
If applicant has experienced victimization through domestic violence, when did this experience last occur?*

Within the past three monthsThree to six months agoSix months to one year agoOne year ago or moreApplicant does not knowApplicant has not experienced victimization through domestic violenceApplicant declines to answer
If the applicant has experienced victimization through domestic violence, is she currently fleeing form the individual(s) that perpetrated abuse against her?*

YesNoApplicant did not experience victimization through domestic violenceApplicant does not knowApplicant declined to answer
Has the applicant ever applied for Massachusetts Victim of Violent Crime Compensation? More information on this can be found here: www.mass.gov/massachusetts-victims-of-violent-crime-compensation*

Yes and the applicant did not qualify for compensationYes and the applicant did qualify for compensationNo the applicant has never applied for compensationOther
Income Guidelines

HUD sets forth the annual income guideline limits for participants in Amirah's Rapid Re-Housing Program. Below are the current income guidelines set forth by HUD. HUD updates these income limits April of every year.
In order to participate in the Amirah Rapid Re-Housing Program, participants may not exceed the current income limits set forth by HUD. Applicants with an income greater than $34,750 are not eligible for this program at this time. Does the applicant meet these income limit guidelines?*

YesNo
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.*

A valid, government-issued photo ID (ex. front & back of state ID, front & back of state driver's license, passport). Please note that we do need to be able to verify a participant's identity prior to her entering into the program.A SIGNED social security cardProof 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
End of Application/Next Steps

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 24 months.*

YesNo
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.*

YesNo
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.*

YesNo
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. She understands that while she is in the Rapid ReHousing Program, she is required to always have an active sublease on file.*

YesNo
If the applicant enters into the Amirah Rapid ReHousing Program, she understands that she will be required to engage in budgeting and financial literacy within the first 6 months of entering into the program.*

YesNo
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.*

YesNo
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. Furthermore, she understands that Amirah will contact local emergency medical services should a medical and/or mental health emergency present.*

YesNo
The applicant may include any additional information she would like to share with Amirah. This is optional.
Applicant's Signature

Clear
Should be Empty:

Amirah's Rapid Re-Housing Application

Applicant's Information

Emergency Contact Information

Homelessness Status

HOUSING HISTORY

Second Most Recent Location

Third Most Recent Location

Fourth Most Recent Location

Fifth Most Recent Location

Additional Housing History

Trigger Activation Warning

Sex Trafficking Screening Tool

Incident Experiencing

Income Guidelines

Required Documents

End of Application/Next Steps