Natural Disaster Relief Form

This form is for natural disaster relief assistance only and must be submitted before an appointment with our Family Support Services Coordinators. For all other assistance inquiries, please click here.

Your CSS Office (Required)

Please choose your CSS Office:

Your form will be forwarded to one of our four Family Support Services Coordinators based on your selection above- please choose the office based on your county:

Lincoln: Serving Butler, Cass, Gage, Jefferson, Lancaster, Polk, Saline, Saunders, Seward, Thayer, and York counties
Hastings: Serving Adams, Clay, Dawson, Fillmore, Franklin, Furnas, Gosper, Hall, Hamilton, Harlan, Kearney, Nuckolls, Phelps, and Webster Counties
Auburn: Serving Johnson, Nemaha, Otoe, Pawnee, & Richardson counties
Imperial: Serving Chase, Dundy, Frontier, Hays, Hitchcock, Lincoln, Perkins, and Red Willow counties

Request (Required)

What do you need help with?

About you

Name (Required)

Phone (Required)

Email (Required)

Your address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Best way to reach you (Required)

SS#

Date of birth (Required)

Gender (Required)

Race & Ethnicity (Required)

Marital status (Required)

Are you a veteran? (Required)

List all who live in the home (provide all details for each person)

Person 2 info

Person 3 info

Person 4 info

Person 5 info

Person 6 info

Person 7 info

Person 8 info

Is anyone in the house disabled? (Required)

If yes, who?

Is anyone in the house pregnant? (Required)

If yes, who?

Due Date

Homeless Management Information System (HMIS) Consumers Informed Consent & Release of Information Authorization

I understand information about me and/or my dependents is entered into a database system called Clarity Human Services. This system helps to better understand homelessness, to improve service delivery, and to evaluate the effectiveness of services provided. Participation in data collection is a critical component of our community’s ability to provide the most effective services and housing possible. The information that is collected is protected by limiting access to the database and limiting what information may be shared. Access to the data and sharing of the data is in compliance with the standards set by the federal, state, and local regulations governing confidentiality of client records. Every person and agency that is authorized to read or enter information into the system has signed an agreement to maintain the security and confidentiality of the information.

By signing this form, I authorize the following: The information collected by this agency will be included in Clarity Human Services and only partner agencies, which have entered into an HMIS Agency Participation Agreement, may use it to:

Produce a client profile at intake that will be shared with collaborating agencies
Produce aggregate level reports regarding use of services
Track individual program-level outcomes
Identify unfilled service needs and plan for enhancements
Allocate resources among agencies engaged in services

I authorize the partner agencies and their representatives to share basic information regarding my family members and/or me. I understand that this information is for the purpose of assessing my/our needs for housing, utility assistance, food, counseling, and/or other services.

The information may consist of the following PPI (Personal Protected Information):

Name
Homeless History
Disabling Condition
Date of Birth
Family Composition Photo (if applicable)
Social Security Number
Income/Non-cash Housing information
Gender
Veteran Status
Health Insurance Status
Ethnicity and Race
Domestic Violence
Client Location
Residence Prior to Project Entry
VI-SPDAT
Program Entry and Exit
Services Provided
Assessment

I Understand That:

The partner agencies have signed agreements to treat my information in a professional and confidential manner. I have the right to view the client confidentiality policies used by the HMIS partner agencies
Staff members of the partner agencies who will see my information have signed agreements to maintain confidentiality regarding my information.
The release of my information does not guarantee that I will receive assistance; my refusal to authorize the use of my information does not disqualify me from receiving assistance.
My records are protected by federal, state, and local regulations governing confidentiality of client records and cannot be disclosed without my written consent unless otherwise provided for in the regulations.
This authorization will remain in effect until I revoke it in writing, and I may revoke authorization at any time, if I revoke my authorization, all information about me already in the database will remain.
This release is valid for one year from the date of my signature below.
I understand I may withdraw my consent at any time.

Partner Agencies: A list of the partner agencies within the HMIS may be viewed prior to signing this form. Auditors or funders who have legal rights to review the work of this agency, including the U.S. Departments of Housing and Urban Development and Nebraska Department of Health and Human Services Homeless Assistance Program may see my complete file in HMIS if services received are funded by their Departments.

By signing, I give authorization to have Protected Personal and relevant Information for me and my dependents entered into the NMIS and shared between Partner Agencies.

This Release of Information will expire three years after the "date signed."

PLEASE NOTE: ALL household persons 18 and older MUST provide a digital signature in order to process your application.

Digital Signature 1

Type your full legal name

Date signed- Signature 1

Digital Signature 2

Type your full legal name

Date signed- Signature 2

Digital Signature 3

Type your full legal name

Date signed- Signature 3

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