BCNC Referral Packet
To request a referral of your client into the Buena Creek Navigation Center, the Cities of Vista and Encinitas are requesting completion of a homeless certification and a narrative of the client’s situation. Please complete the homeless certification completely (to include originating City and DOB ), chronic homeless certification as needed, and check any special needs the client may have. Please note that special needs may delay client admittance due to limited availability of resources. Attach a narrative to the packet, which should include client’s current housing situation, information on barriers to housing/shelter, and a summary service plan. This information should be considered a “warm handoff” for Navigation Center staff to continue the work that has been done by outreach staff, as such please include any other information that you feel would be pertinent to Navigation Center staff. If a VI-SPDAT has been completed, please submit client’s score, and ensure client has been Checked-In through CES prior to entrance into the Navigation Center.
CHRONIC HOMELESS CERTIFICATION - Buena Creek Navigation Center (BCNC)
BCNC Applicant Name: ______________________________________________ DOB: __________________
This is to certify that the above-named individual has been:
• A homeless individual with a disability as defined in section 401(9) of the McKinney-Vento Assistance Act (42 U.S.C. 11360(9)), who:
o Lives in a place not meant for human habitation, a safe haven, or in an emergency shelter, and o Has been homeless and living as described for at least 12 months* or on at least 4 separate occasions in the last 3 years, as long as the combined occasions equal at least 12 months and each break in homelessness separating the occasions included at least 7 consecutive nights of not living as described. • An individual who has been residing in an institutional care facility for less, including jail, substance abuse or mental health treatment facility, hospital, or other similar facility, for fewer than 90 days and met all of the criteria of this definition before entering that facility** or • A family with an adult head of household who meets all of the criteria of this definition, including a family whose composition has fluctuated while the head of household has been homeless. *A “break” in homeless is considered to be 7 or more nights. **An individual residing in an institutional care facility does not constitute a break in homelessness.
Authorized Agency Representative Signature: _________________________________________ Date: ______________________
Client Signature: ______________________________________ Date: ____________________
Does the client have special needs? Please check below.
o Client with pet(s). What type and how many: _____________________________________ o Client needs to be on a lower floor unit due to a disability. o Client needs to be on a female only floor.
o Client needs Spanish speaking case management.
o Client needs to share a room with a specific individual. o Other: ________________________________________
HOMELESS CERTIFICATION - Buena Creek Navigation Center (BCNC)
BCNC Applicant Name: ______________________________________________ DOB: __________________
This is to certify that the above named individual or household is currently homeless based on the information and signature below indicating their current living situation. The individual is spending at least 50 % of residence in, employment within, or became homeless in the City of ____________________.
Check only one box and complete only that section
Living Situation: place not meant for human habitation (e.g., cars, parks, abandoned buildings, streets/sidewalks)
The person named above is currently living in (or, if currently in hospital or other institution, was living in immediately prior to hospital/institution admission) a public or private place not designed for, or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus station, airport, or campground.
Description of current living situation:
____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Homeless Street Outreach Program Name:_________________________________________________________________________ This certifying agency must be recognized by the local Continuum of Care (CoC) as an agency that has a program designed to serve persons living on the street or other places not meant for human habitation. Examples may be street outreach workers, day shelters, soup kitchens, Health Care for the Homeless sites, etc.
Authorized Agency Representative Signature: _________________________________________ Date: ______________________
Client Signature: ______________________________________ Date: ____________________ Living Situation: Emergency Shelter
The person named above is currently living in (or, if currently in hospital or other institution, was living in immediately prior to hospital/institution admission) a supervised publicly or privately operated shelter as follows:
Emergency Shelter Program Name: _____________________________________________________________ This emergency shelter must appear on the CoC’s Housing Inventory Chart submitted as part of the most recent CoC Homeless Assistance application to HUD or otherwise be recognized by the CoC as part of the CoC inventory (e.g. newly established Emergency Shelter).
Authorized Agency Representative Signature: _________________________________________ Date: ______________________
Client Signature: ______________________________________ Date: ____________________ Living Situation: Transitional Housing
The person named above is currently living in a transitional housing program for persons who are homeless. The persons named above is graduating from or timing out of the transitional housing program:
Transitional Housing Program Name: ____________________________________________________________ This transitional housing program must appear on the CoC’s Housing Inventory Chart submitted as part of the most recent CoC Homeless Assistance application to HUD or otherwise be recognized by the CoC as part of the CoC inventory (e.g. newly established Transitional Housing program).
Immediately prior to entering transitional housing the person named above was residing in:
emergency shelter OR a place unfit for human habitation
Authorized Agency Representative Signature: _________________________________________ Date: ______________________
Client Signature: ______________________________________ Date: ____________________