Navigator Forms-Links 

*************************** NOT A PUBLIC PAGE *****************************

Rural Navigation

Request form for Rural Navigation
​to share with agency referral partners 

Housing Stability Services

Intake Form (All fields)

• WHEN TO USE: When the client is present to sign the form or is willing to complete the form themselves with the link.  
• HOW TO USE: 
  • In person: Navigator click the link to open the Intake Form. Review the Tennessen Warning with the client. Complete the form pages 2-5 by asking the client the questions. Have the client enter their signature.  Date the form as of program entry, then submit. Retain the form in the client file.  
  • Send to participant: Navigator review the form with the client. Navigator *right click* on the link and choose to Copy link address. Paste the link in an email to the client with instructions to complete the form and submit. Retain the form in the client file. 

​ 
Intake Form (Tennessen and signature page only + hard copy) 

• WHEN TO USE: When the client is not present to sign the form (e.g. phone- or Zoom-based intake) and cannot complete the form themselves with the link.  
• HOW TO USE: 
  • Navigator complete form pages 2-5 while on phone or Zoom with client. Save the document and send to the client's email for review. Ask the client to review accuracy and either sign using the link or inform you of corrections before signing. Retain 3 items in the client file: 1) Signature page document, 2) Form pages 2-5 as completed and reviewed by the client, and 3) the Email sent to the client to request review and signature.
  • Email language for sending the Tennessen and signature page only version
    Thank you for meeting with me to begin Housing Problem Solving services. As we talked about, one program that helps to pay for this service is called Housing Stability Services and it uses a specific intake form. We filled in form together, but it still requires a signature from you. Please review the attached document with pages 2-5 to check that it is correct for your household. If it is correct, please use this link to sign the form. If it is not correct, please let me know what corrections are needed and I will resend it to you.  

 
​HSS Income limits (80% Area Median Income)