Housing Supports Program-Eligibility

Housing Supports Program Eligibility Form

Through NJ FamilyCare, we’re here to help Medicaid members find and keep safe, stable housing.

Our supports include:
-Assistance with finding housing that fits needs and budget
-Moving assistance to ensure a smooth transition
-Move-in supports and help setting up the home
-Ongoing tenancy case management to maintain housing stability
-Home modifications for safety and accessibility
-Guidance with navigating housing vouchers and other resources
-Chore Support to maintain a clean, comfortable space

To qualify, you must:
-Be facing housing instability or homelessness
-Have NJ FamilyCare (Medicaid)
-Live in New Jersey
-Have a medical or behavioral health diagnosis

Click here to learn more about the Housing Supports Program!

Please complete the referral questions below so we can get started. housing@legacyempowers.com | 732-523-0769 ext. 3

Member's Full Name

First NameLast Name

Member's Date of Birth

Date

Member's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Current Home Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Member's Email Address

example@example.com

Medicaid ID (Found on insurance card)

Managed Care Organization (MCO)

MCO Care Manager

MCO Member ID (Found on insurance card)

Services Requested

The program offers four core services to help members secure and maintain housing. Please select which service(s) are being requested:

Social Risk Factors

Do you and/or the member meet any of the social risk criteria listed below? Check all applicable boxes.

Please explain your current housing situation, including household members:

Do you and/or the member meet any social risk criteria listed below? Check all applicable boxes.

Please provide more information if you are comfortable with disclosing more information that will help us with supporting you:

Duplication of Services & MLTSS

Is the member getting housing help paid for by Medicaid from another program? (Examples: MLTSS Community Transition, MLTSS Home Modifications)

Does anyone else in the member’s household get housing help through Medicaid?

Is the member enrolled in Managed Long Term Services & Supports (MLTSS)?

If yes, is the member getting housing-related help through MLTSS (like Community Transition or Home Modifications)?

Is the member starting or ending MLTSS?

Household Information

Total number of people in household (regardless of Medicaid enrollment status):

Household Member(s) First & Last Name:

Age of household member(s):

Housing Details

Do you or the member currently have a Supportive Housing Connection or Housing Choice (Section 8) voucher?

What is the member’s or household’s monthly rent budget, or the maximum amount allowed by their voucher? (Example: $800 per month)

Where does the member currently live? Who do they currently live with?

When is the lease end date for the member(s)? (if applicable)

Level of supervision required for the member

Does the member need a Live-in Aide? Please note: If so, this is not a service that Legacy can request or provide. This service is requested by the Support Coordinator prior to services being provided/set up.

Background & Financial

Does the member have a criminal record?

Is the member currently employed? If yes, please provide the place of employment, number of hours worked per week, and hourly pay.

What is the members' current monthly and/or annual income?

If known, please provide the member's credit score.

Does the member have any debt? If yes, please select all that apply:

How much is the member's debt?

Has the member ever been evicted? If yes, please add the reason.

Does the member have any pets? If so, what type of pet(s) and what are their name(s)?

Is there any additional information we should know?