Coc Program Participant Disability Verification Form (Page 2 of 2) in pdf

Coc Program Participant Disability Verification Form Page 2

CoC Program Participant

Disability Verification Form

Option #2: Verification by a Qualified Licensed Professional

(Certifying professional must be licensed by the State to diagnose and treat the qualifying condition.)

I, hereby, certify that _________________________________________________(Insert Participant

Name) has been diagnosed with at least one of the following:

 A physical, mental, or emotional impairment, including an impairment caused by alcohol or

drug abuse, post-traumatic stress disorder, or brain injury that: Is expected to be long-

continuing or of indefinite duration; and substantially impedes the individual's ability to live

independently; and could be improved by the provision of more suitable housing conditions;

 A developmental disability, as defined in section 102 of the Developmental Disabilities

Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15002); OR



The disease of acquired immunodeficiency syndrome (AIDS) or any condition arising from the

etiologic agency for acquired immunodeficiency syndrome (HIV).

Check here to indicate that additional information regarding diagnosis has been attached



(optional).

Notes (optional):



Information About the Certifying Licensed Professional

Signature of Licensed Professional:

Credentials:

Date:

Printed Name:

Organization:

License #:

Phone #:

Option #3: Intake or referral staff observation

Must be confirmed within 45 days of the application for assistance by evidence from Option #1 or #2 above.

I hereby certify that ________________________________________________(Insert Participant

Name) meets the HUD definition of disability.

Signature of Staff:

Title:

Date:

Printed Name:

Organization:

2 |

P a g e

U p d a t e d 9 / 1 1 / 2 0 1 5

Coc Program Participant Disability Verification Form Page 2