Instructions for SPA Paper Application

*This application is to be used by individuals whom do not have access to the online login system.
Please complete each field accordingly. Items left blank may cause the application to be placed on hold until that information is submitted. The requested documents must be submitted with the application in order for it to be processed completely.
The items below are to be used for your reference when completely the application. Please select only from these options for these particular items.

Individual Information Section (Pages 1-2)

*Please select the County where the applicant currently resides and is a resident.

*Housing Program Requested - Please select from the following Levels of Care (LOC):
-Supervised Community Residence (CR)
-Supervised Single Room Occupancy Community Residence (CR-SRO)
-Apartment Treatment (ATP)
-Supported Housing (SHP)
-Supported Single Room Occupancy (SP-SRO) – Suffolk Only (NOT TO BE CHOSEN YET AS THIS LEVEL IS NOT DEVELOPED YET)

*Specialized Housing – Please select from the following types:
- MICA
-Young Adult (Nassau 18-30, Suffolk 18-26)
-MI/MR (Mental Illness/Mental Retardation) (DO NOT CHOOSE IF CLIENT DOES NOT HAVE DOCUMENTATION TO SUPPORT A DEVELOPMENTAL DISABILITY)
-Family (Supported Housing Only)
-Couple (Supported Housing Only)
-Veterans (Limited, Suffolk Only)
-Senior Citizens/Geriatric (Nassau Only – Over 55)
-Forensic (Nassau Only)

Skills and Supports (Page 4)

*Applicant Skills – Please select from one of the following:
1- (Cannot accomplish independently)
2- (Accomplish with assistance)
3- (Can accomplish independently)
4- (Unknown)

Psychiatric Information (Page 5)

*Medication Adherence (Compliance) – Please select one of the following:
- Independent
- Supervision
- Reminders

Documents (Page 9)

*Please submit a Psychiatric Evaluation that is signed by a Psychiatrist (MD or DO) or Psychiatric Nurse Practitioner (NPP) and dated within 2 years of application being submitted.
*Please submit a Psychosocial Evaluation that is signed by Psychiatrist (MD or DO), Psychiatric Nurse Practitioner (NPP), Licensed Social Worker, LMHC or a Ph.D and dated within 2 years of application being submitted.
*Physical Exam and PPD must be within 1 year of application being submitted.
*Physician’s Authorization Form (PAF) must be signed by licensed Physician or Psychiatrist. (Only used for Supervised (CR) and Apartment Treatment)