HRA 2010e - HRA

Human Resources Administration

Serving New Yorkers with Care & Compassion


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HRA 2010e Supportive Housing Application

Required Documentation

Below are the required documents needed to complete and submit a 2010e application. All application material must be uploaded to the HRA Placement Assistance and Client Tracking (PACT) system.

Demographic Data

Name including alias, Address, Borough, Family Composition (if application is for a family), SSN, DOB, Gender, Income/Entitlements, Education, Marital Status, Ethnicity, Primary Language, Citizenship, Important Contacts

Verification that the HIPAA Compliant Authorization is signed by applicant and the agency has a record of the original form

Current Housing Location

Housing/Homeless history including dates; Housing type, Facility name, Street address. If applicant was homeless on the streets or non-municipal shelters, documentation must be attached to the application providing more specific information including dates of homelessness and description of homelessness (places stayed, the more specific the better)

Clinical Assessment

Clinical Disorders and Other Conditions that may be a focus of Clinical attention as defined by the DSM-IV-TR or DSM-5

Assisted Outpatient Treatment (AOT) or Assertive Community Treatment (ACT) status

Activities of Daily Living

Checking any ADLs the applicant may require assistance with due to a medical or mental health conditions previously indicated. Provide explanation for any items checked. List includes: Feeding and Meal Preparation; Housekeeping; Managing Finances; Personal Hygiene; Traveling: Hearing; Sight; Cognitive Functions

Medications

List names of psychotropic and non-psychotropic medication in appropriate category. Indicate level of support applicant will need to maintain medication compliance once they are housed

Current Treatment/Service Providers

List of applicant’s current treatment and service providers, including, but not limited to, medical, mental health and case management services providers/programs, Health Home

Managed Long Term Care (MLTC) / Insurance provider

Domestic Violence

If applicant was a victim of DV, information about the services received and how long ago the domestic violence occurred

Hospitalization History

Age of first psychiatric hospitalization; # of psychiatric hospitalizations in the past 3 years; Name of hospital, dates of admission/discharge and service (psychiatric or medical)

Health and service providers in need of more information on the HRA PACT system can contact the PACT technical user support at 929-221-4515 or email hracassupport@hra.nyc.gov.
For assistance completing the 2010e, contact CUCS (www.cucs.org) at (212) 801-3300.