×
Sign out
Your session has timed out.
Click here
to access the application.
minutes
×
Popup Window
...
×
...
...
DASH - Household Referral and Action
Opens in a new tab
Added emails
0
Incorrect emails
0
Skipped emails
0
Add users to selection
Skip unregistered users
Drag and drop csv file with emails
Close
Import
Document Assistance and Supports for Housing - Household Referral and Action Form
This form should be used by the following entities: (1) a DCA DHCR Field Office or (2) a current DASH grantee/provider. Please complete the section(s) below. Should you have any questions or concerns please reach out to OHP providing your Submission ID which can be found in the confirmation email.
Date of referral
*
Date
form field Date of referral
must be in the format: MM/dd/yyyy
Type of Referral
*
Field Office- Referral
DASH (Walk- In)
Field Office Referral
Field Office
*
Value is not selected
-- Select one --
Atlantic / Cape May
Burlington / Camden
Cumberland / Gloucester / Salem
Essex
Hudson
Mercer
Middlesex
Monmouth
Morris / Sussex / Warren
Ocean
Passaic / Bergen
Somerset / Hunterdon
Union
Agency
*
Value is not selected
-- Select one --
Hide - DASH Agency Email
*
Email
form field Hide - DASH Agency Email
is not in correct form
Field Office / Case Manager First Name
*
Field Office / Case Manager Last Name
*
Field Office / Case Manager Email Address
*
Email
form field Field Office / Case Manager Email Address
is not in correct form
Supervisor Name
*
Supervisor Email
*
Email
form field Supervisor Email
is not in correct form
Date HCV Issued to Client
*
Date
form field Date HCV Issued to Client
must be in the format: MM/dd/yyyy
HCV Expiration Date
*
Date
form field HCV Expiration Date
must be in the format: MM/dd/yyyy
Voucher Size
*
Form field Voucher Size has
Invalid numeric value.
Voucher Amount (FMR)
-- Select one --
$ (USD, US Dollar)
€ (EUR, Euro)
¥ (JPY, Japanese Yen)
£ (GBP, British Pound)
Fr (CHF, Swiss Franc)
$ (CAD, Canadian Dollar)
$ (AUD, Australian Dollar)
$ (HKD, Hong Kong Dollar)
R$ (BRL, Brazilian Real)
$ (CLP, Chilean Peso)
¥ (CNY, Chinese Yuan Renminbi)
Kč (CZK, Czech Koruna)
kr (DKK, Danish Krone)
Ft (HUF, Hungarian Forint)
₹ (INR, Indian Rupee)
Rp (IDR, Indonesian Rupiah)
₪ (ILS, Israeli New Shekel)
₩ (KPW, Korean Won)
RM (MYR, Malaysian Ringgit)
$ (MXN, Mexican Peso)
$ (NZD, New Zealand Dollar)
kr (NOK, Norwegian Krone)
Rs (PKR, Pakistan Rupee)
₱ (PHP, Philippine Peso)
zł (PLN, Polish Zloty)
₽ (RUB, Russian Ruble)
$ (SGD, Singapore Dollar)
R (ZAR, South African Rand)
kr (SEK, Swedish Krona)
T$ (TWD, Taiwan Dollar)
฿ (THB, Thai Baht)
t (TRY, Turkish Lira)
₴ (UAH, Ukraine Hryvnia)
Currency
Form field Voucher Amount (FMR)
requires format 1000.00
Recertification
*
Yes
No
Recertification Expiration Date
*
Date
form field Recertification Expiration Date
must be in the format: MM/dd/yyyy
Client Information
Agency
*
Value is not selected
-- Select one --
Collaborative Support Programs of New Jersey, Inc.
Family Promise of Essex County
Family Promise of Sussex County
Family Promise of the Jersey Shore
Heart of Hannah
HomeFront, Inc.
Jewish Family Services of Atlantic and Cape May Counties
Just Believe NJ
Lunch Break
Puerto Rican Action Committee of Southern New Jersey, Inc.
Puerto Rican Assn. for Human Development, Inc.
United Community Corporation
Volunteers of America Delaware Valley, Inc.
Volunteers of America- GNY Passaic
Volunteers of America- GNY Union
Field Office
*
Value is not selected
-- Select one --
Hide - Field Office Email
*
Email
form field Hide - Field Office Email
is not in correct form
Has the household received their Tenant Information Form (TIF)?
*
Yes
No
Voucher and Recertification Packet
*
Form field Voucher and Recertification Packet has
Invalid files.
Has the household ever served in the military or NJ National Guard?
*
Yes
No
Unsure
Is the household participating in the Bringing Veterans Home (BVH) initiative?
*
Yes
No
Based on the previous information entered, this household is potentially eligible to participate in the Bringing Veterans Home (BVH) initiative that serves persons that have served in the military or NJ National Guard and that are currently or soon-to-be experiencing homelessness in the State of New Jersey. Would the household like to be referred for BVH?
*
Yes
No
Household NJ HMIS Personal ID
XXXXXX-XXXX-XXXXX
Client First Name
*
Client Last Name
*
Client Date of Birth
*
Date
form field Client Date of Birth
must be in the format: MM/dd/yyyy
Client Phone number
*
Phone
form field Client Phone number
must be in the format: (000) 000-0000
Client Email
Email
form field Client Email
is not in correct form
Client Marital Status
*
Single
Married
Common Law
Divorced
Separated
Remarried
Widow(er)
Civil Union
Describe the household's challenges in obtaining documentation or in finding housing, below. Please provide as much detail as possible (i.e. specific documents needed/ disability accomodations/ etc.)
Upload Supporting Documents
*
Form field Upload Supporting Documents has
Invalid files.
Hide - Requester Email Final
*
Email
form field Hide - Requester Email Final
is not in correct form
Bringing Veterans Home (BVH)
Current Housing Situation:
Please select the best description of your or your client's current housing situation and circumstances:
*
Please select the best description of your or your client's current housing situation and circumstances:
No Permanent Home: I do not have a stable place to sleep at night.
Unsafe Living Conditions: I am staying in a place not meant for living (e.g., car, park, abandoned building)
Temporary Shelter: I am living in a shelter or hotel paid for by assistance programs.
Recent Discharge: I am leaving a hospital or jail after a short stay and was homeless before.
Couch Surfing: I am temporarily staying with friends or family.
Frequent Moves: I often change where I stay to avoid living on the streets.
Housing Instability: I have lost stable housing multiple times in the past year.
Escaping Harm: I am trying to leave a dangerous situation (e.g., domestic violence, stalking).
No Safe Options: I have no safe place to live.
Lack of Resources: I do not have the money or support to find safe, permanent housing and may soon be homeless.
Unsure/None of the above
Shelter Program/Motel Name
*
Please describe the applicant's current housing situation
Are you currently working with any other veteran housing services?
*
Yes
No
Unsure
What veteran housing service are you working with?
*
Current Location
What is the physical address (or the address of the nearest landmark) of the household? - For Example: 101 S Broad St, Trenton, NJ 08625
*
Which county would you like to live in?
*
Value is not selected
-- Select one --
ATLANTIC
BERGEN
BURLINGTON
CAMDEN
CAPE MAY
CUMBERLAND
ESSEX
GLOUCESTER
HUDSON
HUNTERDON
MERCER
MIDDLESEX
MONMOUTH
MORRIS
OCEAN
PASSAIC
SALEM
SOMERSET
SUSSEX
UNION
WARREN
Hide - Grantee
Hide - Grantee Email
*
Email
form field Hide - Grantee Email
is not in correct form
Alternative Contact(s)
Alternative Contact Name
Alternative Contact Phone Number
Phone
form field Alternative Contact Phone Number
must be in the format: (000) 000-0000
Alternative Contact Email Address
Email
form field Alternative Contact Email Address
is not in correct form
Referral Acceptance Acknowledgement
DASH Case Manager First Name
*
DASH Case Manager Last Name
*
DASH Case Manager Phone Number
*
Phone
form field DASH Case Manager Phone Number
must be in the format: (000) 000-0000
DASH Case Manager Email
*
Email
form field DASH Case Manager Email
is not in correct form
Security Check: Please complete the captcha below to verify that you are not a robot
Email Address:
Back to Dashboard
Continue Editing
Send
Close