Housing Coordination Authorization

Housing Coordination Authorization

Amethyst Recovery Solutions and affiliated recovery support staff may assist individuals in identifying, applying for, coordinating, and accessing recovery housing and other supportive services.To provide this assistance, we may need to communicate with housing providers and related organizations regarding your housing needs, eligibility, referral status, and service coordination.
Name (as it appears on government documents)

First NameLast Name
Preferred Name (if different than above)
Date of Birth

MonthDayYear
Date
Gender Identity

Other
Is there anything we should know to help identify housing options that are safe, appropriate, and comfortable for you?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Recovery Pathway (select all that apply)

Other
I authorize Amethyst Recovery Solutions and its representatives to communicate with recovery residences, sober housing providers, shelters, supportive housing programs, housing assistance agencies, treatment providers, recovery organizations, and other organizations reasonably necessary to assist with securing housing or supportive services on my behalf.
Are there any organizations you do NOT want us communicating with?
If yes, please list organizations below
List organizations you are NOT ok with us communicating with
I authorize Amethyst Recovery Solutions to exchange information reasonably necessary to assist with housing placement, referral coordination, recovery support services, and related care coordination. This may include:

• Contact information
• Demographic information
• Housing needs and preferences
• Recovery support needs
• Program participation and attendance information
• Referral and application status
• Eligibility information
• Assessment and intake information necessary for housing placement
• Other information reasonably necessary to coordinate housing and supportive services
I agree to the above
I authorize Amethyst Recovery Solutions staff to:

• Discuss housing options and supportive services with providers on my behalf
• Verify availability and eligibility requirements
• Submit referrals and applications
• Exchange documents required for placement or services
• Schedule or coordinate intake appointments
• Discuss my referral, application, or placement status
• Advocate on my behalf regarding housing placement and supportive services
• Coordinate services with organizations involved in securing housing, treatment, recovery support, or other related services
I agree to the above
I understand that:

• Signing this authorization is voluntary.
• I may revoke this authorization at any time by providing written notice to Amethyst Recovery Solutions, except to the extent that action has already been taken in reliance upon this authorization.
• Refusing to sign this authorization will not affect my ability to receive services from Amethyst Recovery Solutions.
• This authorization allows Amethyst Recovery Solutions to assist me with housing placement, referral coordination, recovery support services, and related care coordination.
• This authorization will expire one (1) year from the date of signature unless revoked earlier in writing.
I agree to the above
Please upload most recent comprehensive assessment.

Cancelof
By signing below, I authorize Amethyst Recovery Solutions to act on my behalf as described in this authorization.
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