DOGWOOD HOUSE - Alameda County Behavioral Health

DOGWOOD HOUSE
Affordable Housing Opportunity
Housing Consortium of the East Bay (HCEB) is pleased to announce the upcoming opening
of Dogwood House in August 2012. All applicants for this housing must first be certified as
MHSA eligible by Alameda County Behavioral Health Care Services (BHCS).
Application deadline is Wednesday, August 8, 2012, 5 p.m.
The address of Dogwood House will be given to MHSA
certified applicants at the Invitation to the Open House.
Developed By:
Features
Located in Livermore, walking distance of
WHEELS Transit bus lines, Livermore
Center, & Rincon Branch Library.
Close to health services and other
amenities.
Recently rehabilitated home with new
paint, kitchen appliances, laundry, and a
landscaped backyard.
Home to be shared by three tenants,
each with their own private bedroom and
mini-fridge with shared kitchen and
bathrooms. Each resident will have
lockable storage areas on the property.
Experienced supportive services and
property management staff willing to
work with all residents to maintain longterm
housing.
Expected GreenPoint Rated (Existing
Homes)
Funded By:
Restrictions & Requirements
Must be certified as MHSA-eligible by BHCS. The HCEB housing application for eligible
applicants will be forwarded for initial screening (credit and background check).
Must be a single adult 18 years or older or an emancipated youth.
Minimum monthly income of $700/month.
Maximum income of $19,000/year or $1,583/month for a single individual (30% of area
median income).
Rent is 30% of SSI or 30% of actual income, whichever is higher.
Must be homeless or at-risk of homelessness.
See second page for next steps
Managed by Housing Consortium of the East Bay
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HousingConsortiumoftheEastBay
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4 Easy Steps to Getting Housing at Dogwood House
Seek BHCS MHSA Eligibility Certification and
1 Questions Regarding
MHSA BHCS Certification?
Complete HCEB Rental Application
Complete the MHSA eligibility form from BHCS and the HCEB
rental application for Dogwood House.. Complete and mail or
fax the MHSA eligibility certification form AND HCEB rental
application to BHCS by August 8, 2012, 5 p.m.
BHCS Housing Services Office
2000 Embarcadero Cove, Box 55
Oakland, CA 94606
Contact 510-777-2112
or email
everyonehome@acbhcs.org
2
FAX (510) 567-8147
If you are eligible for MHSA housing,* your HCEB rental
application will be processed. Only individuals certified as MHSA
eligible will be considered for Dogwood House.
Attend Open House
All MHSA certified applicants will be invited to attend an Open
House and Orientation at the home on July 17, 2012.
Applicants are encouraged to attend.
Questions Regarding HCEB
Rental Application?
Contact 510-828-6295 or
email
propertymanagement@
hceb.org
3
HCEB Applicant Screening
HCEB Rental Applications will be reviewed for eligibility and
completeness. A lottery will be used to help select final tenants,
if necessary.
4
Applicant Acceptance or Denial
If you are accepted, you will receive an Approval Letter
outlining the move in process at Dogwood House.
*MHSA Housing Eligibility
1) Be enrolled in an MHSA‐funded Full Service Partnership (FSP) program and receiving ongoing housing assistance from the
program OR
2) Have a documented serious mental disorder or serious emotional disturbance as defined in California law AND be homeless or
at‐risk of homelessness as defined by Housing and Urban Development (HUD) HEARTH Act regulations.

ALAMEDA COUNTY MENTAL HEALTH SERVICES ACT (MHSA)
HOUSING PROGRAM ELIGIBILITY CERTIFICATION FORM
DOGWOOD HOUSE
Overview: Located in the City of Livermore, Dogwood House is a 3 bedroom and 2 bathroom home providing
permanent supportive housing to homeless individuals who have a documented serious mental illness.
Dogwood House operates on a shared housing model in which individual tenants rent a single, private bedroom
and agree to share the common areas for the house including the kitchen and bathroom facilities. The common
living spaces and individual bedrooms are furnished with basic furniture and household items, including tables,
chairs, bed frames, mattresses, dressers, and cooking and dining essentials.
The property is operated by Housing Consortium of the East Bay (HCEB).
Individuals applying for one of the 3 spaces at Dogwood House must be homeless AND have a SERIOUS MENTAL
ILLNESS AND must be certified as eligible for Dogwood House by the Alameda County Behavioral Health Care
Services (BHCS) Housing Services Office (HSO).
COMPLETE THE FOLLOWING FORM TO OBTAIN BHCS CERTIFICATION FOR DOGWOOD HOUSE.
Instructions: Please read the entire MHSA Housing Eligibility form and the Dogwood House application materials
before completing them. Complete this two page form for the Dogwood House MHSA Eligibility Certification
and provide the appropriate documentation to verify that you meet the eligibility criteria: serious mental illness
AND homeless housing status.
In addition, please complete the Dogwood House Rental Application.
Submit the 1) MHSA Eligibility Certification Form with the verification of homelessness and documentation of
serious mental illness, and 2) Dogwood House Rental Application by Wednesday, August 8, 2012, by 5 p.m. All
supporting documents and applications should be mailed or faxed to Alameda County Behavioral Health Care
Services-Housing Services Office, 2000 Embarcadero Cove, STE 400 – Box 55, Oakland, CA 94606.
Fax: (510) 567-8147
The deadline for all applications and documentation is Wednesday, August 8, 2012, 5 p.m.
Please contact staff at (510) 777-2112 or everyonehome@acbhcs.org with questions.
Print Name of Applicant (qualifying individual):
Date of Birth (Month/Date/ Year):
Social Security Number:
Current Contact Address, City, Zip Code (if applicable):
Current Contact Phone Number (if applicable):
Verification of Serious Mental Illness: The APPLICANT must provide records that document their eligibility for MHSA Housing.
Documentation must include information that clearly states the applicant meets the definition of serious mental illness (as
defined in California Welfare and Institutions Code Section 5600.3 (b)(1)) (as defined in California Welfare and Institutions Code
Section 5600.3 (a)(1)). By completing and signing this application, the applicant authorizes BHCS to contact a specific provider
or search BHCS records for verification of serious mental illness or serious emotional disturbance. NOTE: The BHCS ACCESS unit
at 1-800-491-9099 provides behavioral health service referral information.
Please complete both pages of this form.

ALAMEDA COUNTY MENTAL HEALTH SERVICES ACT (MHSA)
HOUSING PROGRAM ELIGIBILITY CERTIFICATION FORM
DOGWOOD HOUSE
CONSENT TO RELEASE OR OBTAIN INFORMATION
I understand to be certified for a MHSA Housing Unit, I must provide documentation that I have a serious mental illness as defined by
California law AND I must be currently homeless. I hereby give my permission to BHCS Housing Services Office staff to contact the following
providers or facilities if there are questions about my eligibility. I give these providers my permission to disclose information to BHCS in order
to verify my eligibility. Please provide specific provider names and contact information:
Print Name of Provider (s):
Contact Information:
Authorized Signature of Applicant:
Date Signed:
Homelessness Verification: Where do you currently sleep? Check the ONE box that applies to you
AND attach the required documentation for the box you checked.
Check
ONE
CURRENT
HOUSING
Place not meant for sleeping: a
vehicle, an abandoned building,
bus-train/subway station/airport
or anywhere outside.
Type of documentation required
Written, signed, and dated statement obtained from a third party regarding the
applicant's whereabouts. If unable to obtain this verification, the applicant may
prepare a short written statement about their previous living place and have the
applicant sign and date the statement.
Emergency shelter
Transitional housing for
homeless persons/ Transitional
Residential Treatment Program
“I’m going to be homeless.”
Imminently at-risk of losing
primary nighttime residence.
Enrolled in a Full Service
Partnership (FSP) program and
receiving housing assistance
through this program
Written, signed, and dated referral/verification from the shelter verifying current
housing.
Written, signed, and dated statement from the program staff indicating that the
individual has been a resident there AND the referring agency's written, signed, and
dated verification as to the individual's homeless status when he/she entered their
program.
Written, signed, and dated verification of current housing situation, lack of subsequent
residence, and lack of resources to obtain permanent housing from a third-party. Selfverification
with appropriate supporting documentation is also acceptable.
Documentation must show: Housing will be lost within 14 days of the application AND
no subsequent residence has been identified; AND the individual or family lacks the
resources or support networks needed to obtain other permanent housing.
Written, signed, and dated verification from the FSP provider agency.
PLEASE INCLUDE THE REQUIRED DOCUMENTATION FOR THE BOX THAT YOU CHECKED.
DOGWOOD HOUSE APPLICATION CHECKLIST:
COMPLETE MHSA PROGRAM ELIGIBILITY CERTIFICATION FORM
INCLUDE SERIOUS MENTAL ILLNESS DOCUMENTATION & CURRENT HOUSING DOCUMENTATION
COMPLETE DOGWOOD HOUSE RENTAL APPLICATION
FAX DOCUMENTS AND APPLICATIONS TO (510) 567-8147 BY WEDNESDAY, AUGUST 8, 2012, OR MAIL TO:
HOUSING SERVICES OFFICE, DOGWOOD HOUSE
2000 EMBARCADERO COVE, STE. 400, BOX 55
OAKLAND, CA 94606
Please complete both pages of this form.

RENTAL HOUSING APPLICATION
ASHLAND NEIGHBORHOOD STABILIZATION PLAN – DOGWOOD HOUSE
APPLICATIONS DUE BY 5 PM ON WEDNESDAY, AUGUST 8 th , 2012
INSTRUCTIONS:
RETURN TO:
1) Complete, sign, and date application. BHCS – Housing Services Office
2) Do not leave sections blank; write “n/a” or “0” instead. 2000 Embarcadero Cove
3) Attach completed MHSA Housing Certification. Suite 400, Box 55
Oakland, CA 94606
HAVE QUESTIONS?
OR FAX TO:
Call BHCS – Housing Services Office at (510) 777-2112 (510) 567-8147
APPLICANT INFORMATION
____________________________________________________________________________________ __________________
FIRST NAME MIDDLE NAME LAST NAME GENDER
______________________________________________
DATE OF BIRTH (MM/DD/YYYY)
______________________________________________________
SOCIAL SECURITY NUMBER (XXX – XX – XXXX)
____________________________________________________________________________________________________________
STREET ADDRESS (where you receive mail)
APT. NUMBER
____________________________________________________________________________________________________________
CITY STATE ZIP CODE
_____________________________________________________
HOME PHONE
___________________________________________________
CELL PHONE
ALTERNATE CONTACT INFORMATION (social worker, case manager, etc.):
___________________________________________________________
CONTACT NAME
___________________________________________________________
RELATIONSHIP TO YOU
_____________________________________________
PHONE
_____________________________________________
AGENCY NAME
EVICTION/CRIMINAL HISTORY (attach additional pages if necessary)
1. Have you ever been convicted of a felony? □ NO □ YES
a. If yes, please provide details and dates for each instance: _________________________
____________________________________________________________________________________
b. You may choose to provide a brief explanation of any negative information listed
above. Please attach additional pages if necessary.
2. Have you ever been evicted for fraud, non-payment of rent, or failure to comply with
lease provisions? □ NO □ YES
a. If yes, please provide details and dates for each instance: _________________________
____________________________________________________________________________________
b. You may choose to provide a brief explanation of any negative information listed
above. Please attach additional pages if necessary.
- 1 of 4 -

______________________________________________________________
APPLICANT NAME
____________________________________
PROPERTY
CURRENT HOUSING INFORMATION
____________________________________________________________________________________________________________
YOUR CURRENT ADDRESS (where you sleep at night)
APT. NUMBER
____________________________________________________________________________________________________________
CITY STATE ZIP CODE
□ EMERGENCY SHELTER □ TRANSITIONAL HOUSING □ OTHER: _______________________________
________________________________ __________________________________ ________________________________
DATE YOU MOVED IN DATE YOU MUST LEAVE BY (if any) MONTHLY RENT YOU PAY (if any)
CURRENT HOUSING REFERENCE (service provider who can verify the information above)
____________________________________________________________________
REFERENCE NAME
____________________________________
PHONE NUMBER
____________________________________________________________________________________________________________
ADDRESS
APT. NUMBER
____________________________________________________________________________________________________________
CITY STATE ZIP CODE
___________________________________________________________
RELATIONSHIP TO YOU
_____________________________________________
AGENCY NAME
PREVIOUS HOUSING INFORMATION
______________________________________________________________________________________
YOUR PREVIOUS ADDRESS
APT. NUMBER
____________________________________________________________________________________________________________
CITY STATE ZIP CODE
□ EMERGENCY SHELTER □ TRANSITIONAL HOUSING □ OTHER: _______________________________
______________________________ _________________________________ __________________________________
MONTHLY RENT (if any) DATE OF MOVE-IN DATE OF MOVE-OUT
REASON(S) FOR MOVING OUT: ______________________________________________________________________________
PREVIOUS HOUSING REFERENCE (someone who can verify the information above)
____________________________________________________________________
REFERENCE NAME
____________________________________
PHONE NUMBER
____________________________________________________________________________________________________________
ADDRESS
APT. NUMBER
____________________________________________________________________________________________________________
CITY STATE ZIP CODE
___________________________________________________________
RELATIONSHIP TO YOU
_____________________________________________
YEARS KNOWN
- 2 of 4 -

______________________________________________________________
APPLICANT NAME
____________________________________
PROPERTY
HOUSEHOLD ASSETS (bank accounts, trusts, real estate, etc.)
□ YES, I/we have assets and have provided the information below:
___________________ ______________________________________________ $ _____ ___
ASSET TYPE FINANCIAL INSTITUTION CURRENT VALUE
___________________ ______________________________________________ $ _____ ___
ASSET TYPE FINANCIAL INSTITUTION CURRENT VALUE
□ NO, I/we do not have ANY assets at this time.
TOTAL CURRENT ASSETS: $ _
HOUSEHOLD INCOME (wages, SS/SSI, food stamps, cash from family, etc.)
□ YES, I/we have income and have provided the information below:
__ __
___________________ ______________________________________________ $ _ __ ____
TYPE OF INCOME SOURCE OF INCOME MONTHLY AMOUNT
___________________ ______________________________________________ $ _ ____ __
TYPE OF INCOME SOURCE OF INCOME MONTHLY AMOUNT
TOTAL MONTHLY INCOME: $
□ NO, I/we do not have ANY income at this time. The resources available to me for
covering basic necessities (food, clothing, medications, etc.) are listed below:
_ _ __
____________________________________________________________________________________________________________
PERSONAL REFERENCE #1
_________________________________________________________________
REFERENCE NAME
______________________________________
PHONE NUMBER
____________________________________________________________________________________________________________
STREET ADDRESS
APT. NUMBER
____________________________________________________________________________________________________________
CITY STATE ZIP CODE
______________________________________________________
RELATIONSHIP TO YOU
_____________________________________________
NUMBER OF YEARS KNOWN
PERSONAL REFERENCE #2
_________________________________________________________________
REFERENCE NAME
______________________________________
PHONE NUMBER
____________________________________________________________________________________________________________
STREET ADDRESS
APT. NUMBER
____________________________________________________________________________________________________________
CITY STATE ZIP CODE
______________________________________________________
RELATIONSHIP TO YOU
_____________________________________________
NUMBER OF YEARS KNOWN
- 3 of 4 -

______________________________________________________________
APPLICANT NAME
____________________________________
PROPERTY
APPLICANT CERTIFICATIONS
APPLICANT
INITIALS
_______ I have attached my completed MHSA Housing Certification and the
required documentation.
_______ I certify that the statements made in this application are true and
complete to the best of my knowledge and belief.
_______ I understand that false statements or information are punishable under
federal law and cause for immediate denial of housing.
_______ I understand that I must provide written notification of any changes to
the information on this form, especially address and telephone number.
_______ I agree to allow HCEB to perform a consumer credit check and criminal
background check including sex offender registry.
_______ I understand that the above information is being collected to determine
eligibility for housing at Dogwood House. I authorize the owner to verify
all information provided on this application and to contact previous or
current landlords, employers, or other sources for credit and verification
information which may be released by appropriate federal, state, local
agencies, or private persons to the landlord or agent.
____________________________________________________________
APPLICANT SIGNATURE
____________________________________
DATE
DID YOU REMEMBER TO:
RETURN TO:
1) Complete, sign, and date application. BHCS – Housing Services Office
2) Do not leave sections blank; write “n/a” or “0” instead. 2000 Embarcadero Cove
3) Attach completed MHSA Housing Certification. Suite 400, Box 55
Oakland, CA 94606
HAVE QUESTIONS?
OR FAX TO:
Call BHCS – Housing Services Office at (510) 777-2112 (510) 567-8147
- OFFICE USE ONLY -
RECEIVED BY HCEB: _____/_____/_________ at ______:______ am
pm INITIALS:__________
- 4 of 4 -

YOU ARE INVITED
DOGWOOD HOUSE
OPEN HOUSE & ORIENTATION
791 Crane Avenue, Livermore, CA 94551
Tuesday, July 17th, 1:00 p.m.—3:00 p.m.
Directions from I-580: Take 580 to Portola Avenue South. Take a right
on Rincon Avenue, and go .75 miles. Make a left on Pine Street and
go .2 miles, then left on Crane Avenue. 791 Crane Avenue is on the
left.
Managed by Housing Consortium of the East Bay
Creating inclusive communities