Pivotal Point Transitional Housing Application

[{viewVars.title}]

Type

[{viewVars.validations.type}]

First Name

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Middle Name

[{viewVars.validations.middleName}]

Last Name

[{viewVars.validations.lastName}]

Date of Birth

[{viewVars.validations.dob}]

SSN

[{viewVars.validations.ssn}]

Phone Number

[{viewVars.validations.phone}]

[{viewVars.validations.email}]

Marital Status

[{viewVars.validations.marital}]

Gender

[{viewVars.validations.gender}]

Highest Level of Education Completed

[{viewVars.validations.education}]

Social Media Handles / Profile Names (Facebook, Instagram, TikTok, X, SnapChat, etc.)

[{viewVars.validations.socialMedia}]

Current Address

[{viewVars.validations.currentAddress}]

Zip Code

[{viewVars.validations.zip}]

Race/Ethnicity

[{pr}]

[{viewVars.validations.race}]

First Name

[{viewVars.validations.DepFirst}]

Middle Name

[{viewVars.validations.DepMiddle}]

Last Name

[{viewVars.validations.DepLast}]

Relationship to Applicant

[{viewVars.validations.relationship}]

SSN

[{viewVars.validations.DepSsn}]

Date of Birth

[{viewVars.validations.DepDob}]

Race/Ethnicity

[{viewVars.validations.DepRace}]

School/Daycare

[{viewVars.validations.school}]

Add a point of contact.

Full name	Relationship	SSN	Date of Birth	Race/Ethnicity	School/Daycare	Action

Have you ever been in Foster Care?

[{viewVars.validations.fosterCare}]

Name and phone number of Case Worker

[{viewVars.validations.caseWorker}]

If yes, when & for how long?

[{viewVars.validations.yesFosterCare}]

Are you a veteran?

[{viewVars.validations.veteran}]

Do you have a disabling condition?

[{viewVars.validations.disabling}]

What mode of transportation do you use?

[{pr}]

What is your current employment status?

[{viewVars.validations.employment}]

Are you currently attending high school?

[{viewVars.validations.attendingSchool}]

Name of school and grade level

[{viewVars.validations.schoolName}]

Do you now, or have you ever had an IEP?

[{viewVars.validations.iep}]

If yes, please describe

[{viewVars.validations.yesIep}]

Are you currently pursuing an education?

[{viewVars.validations.pursuingEducation}]

If yes

[{viewVars.validations.yesPursuingEducation}]

Please upload a copy of criminal record

[{viewVars.validations.criminalRecordFile}]

View Recent H&P Delete file

Please provide the name of your employer

[{viewVars.validations.employerName}]

Start date of employment

[{viewVars.validations.employmentStart}]

Pay rate / salary

[{viewVars.validations.salary}]

Average hours worked per week

[{viewVars.validations.hoursPerWeek}]

Previous employer name

[{viewVars.validations.previousEmployer}]

How long did you work for this employer?

[{viewVars.validations.workForEmployer}]

Reason for leaving

[{viewVars.validations.leavingReason}]

Do you receive any of the following additional incomes?

[{viewVars.validations.additionalIncomes}]

Other - Do you receive any of the following additional incomes?

[{viewVars.validations.yesIep}]

What debt do you currently owe (check all that apply)?

[{pr}]

Other - What debt do you currently owe

[{viewVars.validations.otherDebt}]

Estimate the total amount of debt you believe you owe

[{viewVars.validations.debtTotal}]

How many evictions do you have?

[{viewVars.validations.evictions}]

How much money do you owe towards your eviction(s)?

[{viewVars.validations.evictionMoney}]

Please list any diagnosed medical conditions

[{viewVars.validations.medicalCondition}]

Please list any mental health diagnoses

[{viewVars.validations.healthDiagnoses}]

Have you ever been hospitalized for mental health reasons? Please provide dates and location

[{viewVars.validations.hospitalized}]

When did you last use drugs or alcohol?

[{viewVars.validations.emergContactEmail}]

Have you ever sought treatment for substance use (e.g. detox, drug and alcohol treatment/recovery center, NA/AA, etc.)?

[{viewVars.validations.substanceUse}]

List any substances you have used/abused, either presently or in the past, and the approximate frequency of use.

[{viewVars.validations.substanceAbuse}]

Are you a victim/survivor of domestic violence?

[{viewVars.validations.domesticViolence}]

If yes, are you currently fleeing?

[{viewVars.validations.currentlyFleeing}]

Have you ever been convicted of a crime?

[{viewVars.validations.convicted}]

If yes, please list each conviction and the year it occurred

[{viewVars.validations.yesConvicted}]

Are you currently involved with Probation and Parole or Drug Court?

[{viewVars.validations.probation}]

Do you currently have a juvenile officer, probation/parole officer, or on legal supervision of any kind?

[{viewVars.validations.juvenileOfficer}]

Briefly explain your circumstance as it relates to housing and why you are applying for the Pivotal Point program

[{viewVars.validations.circumstance}]

I, [{viewVars.referral.firstName&& viewVars.referral.lastName?(viewVars.referral.firstName+' '+viewVars.referral.lastName)+',':''}] declare that under penalty of perjury that all statements above are true and correct.

[{viewVars.validations.consent}]

Electronic Signature

[{viewVars.validations.signature}]

Right to Deny Services

Pivotal Point reserves the right to not admit persons into the Transitional Housing Program. Applicants may be denied acceptance or continuance in the program for reasons including, but not limited to.
Use or possession of alcohol, firearms, violence or illegal drugs or activity is prohibited (drug and alcohol tests may be randomly administered and required).
Evidence of smoking inside the buildings, apartments, offices, or on wooden decks or grass.
Inability or unwillingness to transition to and maintain self-sufficiency.
Inability to obtain and maintain a minimum of 35-40 hours per week on the job or combined total for work and school.
Inability or unwillingness to follow the Resident Guidelines as stated below.
Zero Tolerance Policy
Pivotal Point Transitional Housing has a ZERO TOLERANCE policy regarding the use of drugs, alcohol, and violence. If accepted into the program, residents will be subject to random drug screenings and apartment checks. If a resident has been found to have violated this policy by using or possessing drugs or alcohol, or becoming violent on the Pivotal Point property or elsewhere, the resident will be subject to immediate dismissal from the program.
Resident Guidelines
The following guidelines are in effect while a resident or family resides in any Pivotal Point apartment. Violation of any guideline will (at the sole discretion of the Board or Staff) result in probation, or be cause for immediate dismissal from the building and the program.
Curfew is 10:00pm. This can only be waived for work schedules, which must be supplied to office staff.
No visitors for the first 2 weeks of the program.
All visitors must be approved through the office before visiting your apartment. Visitors must be out of the apartment before curfew at 10pm and should not arrive before 7am. Quiet hours are 10pm-7am.
No overnight visitors are allowed.
No visitors are allowed in the apartment if you are not home.
Children under the age of 13 must be attended by an approved adult at all times.
Children must be enrolled in the local school district and attend school every day.
No animals of any kind will be allowed.
No burning of candles, incense, or wax warmers are allowed on the premises. Oil diffusers are allowed.
Residents must keep apartment units and common areas clean and neat according to the handbook.
Aggressive, violent, threatening, or bullying behavior towards anyone will not be tolerated and could result in dismissal from the program. Residents are expected to display respectful behavior towards staff, volunteers, and other residents.
Stealing property belonging to Pivotal Point or other residents can result in immediate termination from the program.
Any legal problems while at Pivotal Point may disqualify you from the program.
All residents living at Pivotal Point are expected to be at work and/or school at least 35-40 hours per week.
All residents must attend scheduled meetings and appointments. Life Skills classes and Case Management sessions are mandatory. Residents must make arrangements with their employer to ensure attendance.
Residents are assigned weekly chores listed on the monthly newsletter, which must be completed twice per week.
A $100 move-in occupancy charge will be taken at time of move-in, or 1st paycheck, to cover costs of cleaning, damage, or non-completion of program. In order to be eligible for a full refund, you must successfully complete the program.
I acknowledge staff may enter my apartment at any time to do maintenance or cleaning checks when I am not present and without notification. I acknowledge that staff may perform random apartment checks and may search personal belongings and property at any time and without notification.
No payday loans, title loans, or credit cards, and no borrowing or lending money from or to friends or family is allowed. No money transfer apps like Venmo, Cashapp, etc. A physical local bank account is required.
Residents agree to follow a weekly budget plan created with the Case Manager, and place needs over wants.
Gambling in-person or through mobile apps is not allowed while in the program.

Pivotal Point reserves the right to not admit persons into the Transitional Housing Program. Applicants may be denied acceptance or continuance in the program for reasons including, but not limited to.
Use or possession of alcohol, firearms, violence or illegal drugs or activity is prohibited (drug and alcohol tests may be randomly administered and required).
Evidence of smoking inside the buildings, apartments, offices, or on wooden decks or grass.
Inability or unwillingness to transition to and maintain self-sufficiency.
Inability to obtain and maintain a minimum of 35-40 hours per week on the job or combined total for work and school.
Inability or unwillingness to follow the Resident Guidelines as stated below.
Zero Tolerance Policy
Pivotal Point Transitional Housing has a ZERO TOLERANCE policy regarding the use of drugs, alcohol, and violence. If accepted into the program, residents will be subject to random drug screenings and apartment checks. If a resident has been found to have violated this policy by using or possessing drugs or alcohol, or becoming violent on the Pivotal Point property or elsewhere, the resident will be subject to immediate dismissal from the program.
Resident Guidelines
The following guidelines are in effect while a resident or family resides in any Pivotal Point apartment. Violation of any guideline will (at the sole discretion of the Board or Staff) result in probation, or be cause for immediate dismissal from the building and the program.
Curfew is 10:00pm. This can only be waived for work schedules, which must be supplied to office staff.
No visitors for the first 2 weeks of the program.
All visitors must be approved by your case manager before visiting the facility. No visitors are allowed in your apartment but may gather in common areas.
No overnight visitors are allowed.
Residents of school-age must be enrolled in the local school district and attend school every day.
No animals of any kind will be allowed.
No burning of candles, incense, or wax warmers are allowed on the premises. Oil diffusers are allowed.
Residents must keep apartment units and common areas clean and neat according to the handbook.
Aggressive, violent, threatening, or bullying behavior towards anyone will not be tolerated and could result in dismissal from the program. Residents are expected to display respectful behavior towards staff, volunteers, and other residents.
Stealing property belonging to Pivotal Point or other residents can result in immediate termination from the program.
Any legal problems while at Pivotal Point may disqualify you from the program.
All residents living at Pivotal Point are expected to be at work and/or school at least 35-40 hours per week.
All residents must attend scheduled meetings and appointments. Life Skills classes and Case Management sessions are mandatory. Residents must make arrangements with their employer to ensure attendance.
Residents are assigned community chores, which must be completed at least once per week.
I acknowledge staff may enter my apartment at any time to do maintenance or cleaning checks when I am not present and without notification. I acknowledge that staff may perform random apartment checks and may search personal belongings and property at any time and without notification.
No payday loans, title loans, or credit cards, and no borrowing or lending money from or to friends or family is allowed. No money transfer apps like Venmo, Cashapp, etc. A physical local bank account is required.
Residents agree to follow a weekly budget plan created with the Case Manager, and place needs over wants.
Gambling in-person or through mobile apps is not allowed while in the program.
All vehicles must have a valid driver’s license, a current vehicle registration, and auto insurance.

Program Rules and Guidelines Acknowledgment

[{viewVars.validations.consent2}]

Purpose of This Release of Information Authorization

This Release of Information (ROI) Authorization is a required component of the program intake process for Pivotal Point Transitional Housing. It allows Pivotal Point to collect, use, and/or disclose limited information necessary to determine eligibility, complete intake assessments, coordinate services, monitor progress or outcomes, program evaluation, ensure health and safety, respond to emergencies, and manage organizational risk and liability. This ROI form relates to the resident, their dependents, and any and all members living in a Pivotal Point apartment.

Information that May be Used or Disclosed

The following is required for intake and must be authorized to enter the Pivotal Point program.
Identifying Information which includes, but is not limited to, name, date of birth, SSN, contact information, address, and more.
All information used for program participation, attendance, and compliance with Pivotal Point rules, regulations, and guidelines.
Incident reports related to safety, security, or rule enforcement.
Emergency contact information.
Information required for funding, audits, or regulatory compliance.
Case management notes, service plans, goals, and progress updates.
Employment, education, or vocational information.
Personal financial information, such as bank account information and transactions, fees, or information used for eligibility purposes and case management services (i.e. debt, monthly bills, credit report, etc.).
Medical or behavioral/mental health information voluntarily disclosed, including substance use information.

Persons or Entities Authorized to Receive Information

Pivotal Point Transitional Housing partners with specific organizations, churches, persons, and entities on a frequent basis. The resident/household acknowledges Pivotal Point Transitional Housing cannot guarantee confidentiality will be respected by the following outside entities/persons and gives consent for the release of the resident’s information (and any household member's information) regardless.
• Any and all Pivotal Point staff members for each of our three locations: Adult facility, Youth facility, and Thrift Store. Examples of such staff members include case managers, directors, office personnel, communications personnel, cleaning and maintenance personnel, contractors, members of our board of directors, etc.).
• Partner agencies and referral organizations including, but not limited to, additional housing shelters, social service agencies, educational facilities, Division of Family Services, Child Support Division, area County courts, Family Guidance Center, DeNovo Recovery Center, Drug Court, Probation and Parole, United Way, Salvation Army, Catholic Charities, and any other partnering agency which will enhance services provided to the resident household.
• Pivotal Point Apartment Sponsors and their involved church and specified members of their congregation, volunteers, life skills facilitators, budget counselors, and any other person or entity identified by Pivotal Point staff and the resident household.
• The resident’s current and past employers and school or college educators.
• Any local or government agencies administering housing or benefit programs.
• Funding sources or auditors.
• Emergency contacts and any family member approved in writing by the resident.
• Legal or regulatory authorities when required by law and police departments when necessary.

Risks of Disclosure

Once information is disclosed, it may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. Electronic and verbal communications carry inherent risks despite reasonable safeguards. Pivotal Point cannot guarantee third parties will protect information once disclosed.

Duration and Expiration of ROI

This authorization becomes effective on the date the resident enters the Pivotal Point program and will remain in effect for a period that does not expire, unless a written request for expiration is given, regarding the welfare of the resident household.

Electronic Records and Signatures

This form states the resident gives consent to the use of electronic records, electronic storage, and electronic signatures where permitted by law.

Release of Information Acknowledgment

[{viewVars.validations.consent3}]

Release and Authorization for Use of Photos and Videos

For valuable consideration, receipt of which is hereby acknowledged. I hereby grant Pivotal Point Transitional Housing the irrevocable right and permission, in connection with the photographs or videos that were taken of me (and my household) or photographs or videos of which I provided to Pivotal Point Transitional Housing, (copies of which are annexed hereto and made a part hereof), the following: the right to use and reuse, in any manner at all, said photographs, in whole or in part, modified or altered, either by themselves or in conjunction with other photographs, in any medium or form of distribution, and for any purposes whatsoever, including, without limitation all promotional and advertisements uses, and other trade purposes, as well as using my name in connection therewith, if Pivotal Point Transitional Housing so desires. I hereby release and discharge Pivotal Point Transitional Housing from any and all claims, actions and demands arising out of or in connection with the use of said photographs, including, without limitation, and all claims for invasion of privacy and libel. This release shall insure to the benefit of the assigns, licenses and legal representatives of Pivotal Point Transitional Housing. I acknowledge and have read the foregoing and fully and completely understand the contents.

Release and Authorization for Use of Photographs and Videos Acknowledgment

[{viewVars.validations.consent4}]

Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint Hazards.Lead Warning Statement.Pivotal Point residents reside in an apartment complex built before 1978. Housing built before 1978 may contain lead-based paint. Lead from paint, paint chips, and dust can pose health hazards if not managed properly. Lead exposure is especially harmful to young children and pregnant women. Before renting pre-1978 housing, lessors must disclose the presence of known lead-based paint and/or lead-based paint hazards in the dwelling.DisclosurePivotal Point has no knowledge of lead-based paint and/or lead-based paint hazards in the apartment complex used for housing program participants. Pivotal Point has no reports or records pertaining to lead-based paint and/or lead-based paint hazards in the housing.Certification of AccuracyThe involved parties have reviewed the information above and certify, to the best of their knowledge, that the information they have provided is true and accurate.

Consent Regarding Risk of Lead-Based Paint Acknowledgment

[{viewVars.validations.consent5}]

Pivotal Point Transitional Housing Handbook Acknowledgement Agreement. The resident agrees to follow all rules and guidelines listed in the Resident Handbook. The resident has asked questions over areas in which the need of clarification or further explanation is necessary for full comprehension. The resident acknowledges that edits, updates, or revisions may be made to the handbook at any time and agrees to comply with any changes to the rules, regulations, or guidelines.

Handbook Acknowledgement

[{viewVars.validations.consent6}]

PARTICIPANT AGREEMENT

1. Pivotal Point is Not a Landlord. By entering into Pivotal Point Transitional Housing, Inc.'s (\"Pivotal Point\") program, Participant acknowledges and agrees that Pivotal Point is NOT acting as a landlord and Participant is NOT a tenant. Participant's participation in the program is purely voluntary on the part of both the Participant and Pivotal Point. Either party may terminate your participation on the program at any time for any reason. Participant agrees that Participant's acceptance into the Pivotal Point program is not a rental agreement, and that this is not a landlord/tenant agreement, but an agreement for temporary homeless shelter transitional housing & supportive services provided by the Pivotal Point program.
2. Requirement For Participant To Follow Pivotal Point Rules. Participant acknowledges receipt of the Pivotal Point expectations and guidelines for participation in the Pivotal Point transitional housing program, attached to this Agreement and incorporated herein by reference. If any of the expectations, rules or guidelines are broken by the Participant, the Participant acknowledges and agrees that the Participant may be asked to immediately terminate participation in the Pivotal Point program, remove all belongings and leave the Pivotal Point premises immediately, without further notice.
3. Agreement to Indemnify and Hold Pivotal Point Harmless. In exchange for Pivotal Point agreement to allow Participant to participate in the Pivotal Point transitional housing program, Participant agrees to indemnify and hold harmless Pivotal Point from and against all damages, claims, liability, fines, injuries arising out of or related to Participant's participation in the Pivotal Point program. This indemnification by Participants includes indemnification of Pivotal Point for all damages, claims, liability fines, injuries to Participant, Participant's family or Participant's guests.
4. NO LIABILITY. BY EXECUTING THIS AGREEMENT, PARTICIPANT AGREES THAT PIVOTAL POINT SHALL NOT BE LIABLE TO PARTICIPANT, PARTICIPANT'S FAMILY, GUESTS, INVITEES, SERVANTS OR OTHERS FOR INJURY TO OR DEATH OF ANY PERSON, ANIMAL OR PET, NOR FOR LOSS OR DAMAGE TO PROPERTY (INCLUDING THE PROPER OF PARTICIPANT) OCCURRING IN OR ABOUT PIVOTAL POINT PREMISES (OR WITHIN THE APARTMENT COMPLEX OF WHICH THE PIVOTAL POINT PREMISES ARE A PART) FROM ANY CAUSE WHATSOEVER, EVEN IF THE CAUSE OR CARELESSNESS OR FAULT OF THE PIVOTAL POINT. PARTICIPANT AGREES TO INDEMNIFY AND HOLD LESSOR HARMLESS FROM ALL LOSS, DAMAGE, LIABILITY, AND EXPENSE, AND THE EXPENSE OF DEFENDING THE CLAIMS, RELATED TO ANY ACTUAL OR ALLEGED LOSS OR DAMAGE TO PIVOTAL POINT PROPERTY CAUSED BY OR RESULTING FROM ANY OCCURRENCE IN OR ABOUT THE PIVOTAL POINT PREMISES ARE A PART, INCLUDING THE ALLEGED NEGLIGENCE, CARELESSNESS OR FAULT OF THE PIVOTAL POINT.
5. No Duties Assumed By Pivotal Point. Participant acknowledges that any security measures provided by Pivotal Point are not to be treated by Participant as a guarantee against crime or a reduction in the risk of crime. Pivotal Point will not furnish security personnel, security lighting, security gates or fences or other forms of security, except as might be required by law. Pivotal Point has no duty to remove sleet or snow. Pivotal Point does not serve as a health care provider and has no duty to check on, monitor or otherwise participate in any way with the Participant's health or personal welfare. Participant is solely responsible for Participant and Participant family's health and welfare.
6. Release of Information Allowed. Participant gives permission for information to be released about Participant and Participant children, by or to any doctor, social worker, counselor, employer, landlord, shelter, agency, & Rosie HMIS databases, or any other person deemed necessary by Pivotal Point.
7. Waiver of Jury Trial. Participant agrees to waive trial by jury in any action, proceeding, or counterclaim brought arising out of or in any way connected with Participant's participation in the Pivotal Point program.
8. Governing Law / Jurisdiction. This Agreement shall be interpreted and governed by the laws of the State of Missouri. Any legal actions arising out of or related in any way to Participant's participation in the Pivotal Point program must be exclusively maintained in the Circuit Court of Buchanan County, Missouri.
9. No Other Agreements: No oral promises, representations or agreements have been made between Participant and Pivotal Point and this Agreement represents the entire Agreement setting forth the terms of participation by the Participant in the Pivotal Point program.
10. Successors and Assigns. Participant agrees this Agreement shall apply and be binding on Participant, Participant's heirs, successors in interest, legal representatives and permitted assigns.
THIS IS A LEGALLY BINDING AGREEMENT. IT CONTAINS IMPORTANT PROVISIONS WAIVING LIABILITY, INDEMNIFYING PIVOTAL POINT AND WAIVING JURY TRIALS. PLEASE READ THE ENTIRE AGREEMENT CAREFULLY. BY SIGNING THIS AGREEMENT, YOU ARE CERTIFYING THAT YOU HAVE READ THE ENTIRE AGREEMENT. BEFORE SIGNING YOU MAY SEEK LEGAL ADVICE TO HELP YOU UNDERSTAND THE TERMS OF THIS AGREEMENT.

Participant Agreement Acknowledgement

[{viewVars.validations.consent7}]

Thank you for your submission. We will contact you shortly.

[{viewVars.title}]

Identifying Information

Dependents

Dependents

Further Information

Education

Employment

Financial

Medical

Legal

Narrative

Consent

Program Rules and Guidelines

Release of Information

Release and Authorization for Use of Photographs and Videos

Consent Regarding Risk of Lead-Based Paint

Handbook Acknowledgement

Participant Agreement