Diver Morning Sky Hope & Healing Center  Pre- App.
Diver Morning Skye Hope & Healing Center is a long -term housing program that targets homeless BIPOC mothers aged 18-24 who are pregnant, working on reunification, or have a child under 24 months. We offer housing and wraparound services. Our ultimate goal is to take families from homeless to homeowners and from harmed to healed.
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Name *
Date *
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DD
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YYYY
Email *
Phone Number *
Secondary Contact Phone Number
What is your race? *
How old are you? What is your birthdate? *
Have you been homeless for the last twelve months or 4 times in the last three years? *
Are you pregnant? *
How many children do you have and what are their ages? *
What is your child's race? *
What is your source of income and the monthly gross amount? *
Do you currently have an open case with CPS?  *
Tell me about your current housing situation. *
Are you or have you dealt with any of the following? *
Required
Referral Agency and contact information *
Is there any additional information that we should know or consider?
Divine Konnections Inc. Authorization for Use and Release of Protected Health & General Information
This release authorizes the exchange of protected health and housing information between Divine Konnections Inc. and the following organizations. Information may include but is not limited to financial, medical, psychiatric, mental health, alcohol, or substance abuse records. The individual has the right to restrict the disclosure of any of the types of information. Your signature on this form authorizes the release of information about the person named above as follows.  
    • Deyona Kirk - Executive Director at Divine Konnections; deyona@divinekonnections.org
    • Jennifer Davey - Housing Director at Divine Konnections; jen@divinekonnections.org
    • Tatianna Kirk - Operations Manager at Divine Konnections, tkirk@divinekonnections.org
    • Tatiana Bergum - Program Director at Divine Konnections; tbergum@divinekonnections.org
    • Jasmin Burch- Annie's House Manager, jburch@divinekonnections.org
    • Brianna Neas - Housing Coordinator at Divine Konnections; brianna@divinekonnections.org
-I understand I have the right to refuse to sign this authorization and understand that refusal may affect the provision of some health care services to me.
-I understand that I can cancel permission to use and disclose my information at any time by notifying the agency in writing. Permission to use and disclose alcohol and drug treatment records can be canceled by talking with my worker. I understand this change will not affect information that has already been shared.
-I understand that federal law protects my health information. However, my information could be shared with agencies or businesses who may not be covered by the federal law. They could then share my information with others.
 -I understand I have the right to inspect or copy (for a reasonable cost) the information I have authorized to be disclosed. 
-I understand I have a right to request a copy of this form after I sign it.
-I understand a photocopy or fax of this form is valid as the original.
-Information may include medical, HIV/AIDS, psychiatric, mental health, or substance abuse records.
Please type your name to agree to the following statement: 
I, _______ here by authorize Divine Konnections Staff to share, disclose, and receive information as needed to provide services. 
 *
Please select all that apply
For Annie's House, please ensure Housing Assistance, Legal/Court Information, Social Services/CPS and Tenant/Landlords is marked.

 *
Required
Information to be released - General /Specific & why information is to be released/shared, please explain: *
Please select all - I understand: *
Required
-This information is needed for the purpose of determining eligibility for services and service planning and coordination. 
-I understand that at any time this release can be rescinded and then no longer be valid. Participant must state in writing that they want the release rescinded. 
-I understand that this release of information will expire one year from the date signed below. Please type your initials.
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Please type your full name and today's date. *
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