HomeMy WebLinkAboutdisability-verification-r Email: HomeStretch@acgov.org | Phone: (510) 567-8017 | Fax: 1 (855) 658-5466
Revised 10/21/2025
Guide to Home Stretch Disability Verification
Instructions: Please use the following guidelines for documenting disability as related to a Home Stretch
referral. This form is intended solely to verify the disability status of the specified individual, which will help
prioritize them for permanent supportive housing opportunities in Alameda County. Completion of this
disability verification form will enable matching to specific housing opportunities.
According to HUD guidelines, a person shall be considered to have a disabling condition if such a person has a
diagnosable:
• Substance use disorder; AND/OR
• Serious mental illness; AND/OR
• Development disability (as defined in Section 102 of the Developmental Disabilities Assistance Bill of
Rights Act of 2000, (42 U.S.C. 15002); AND/OR
• Post-traumatic stress disorder (PTSD); AND/OR
• Cognitive impairments resulting from brain injury; AND/OR
• Chronic physical illness or disability (e.g. HIV/AIDS)
And that condition meets all the criteria below:
• Is expected to be of long-continued and indefinite duration; AND
• Substantially impedes the person’s ability to live independently; AND
• Is of such a nature that the ability to live independently could be improved by more suitable housing
conditions.
There are specific housing opportunities with set-asides or preferences for people with the following health
conditions: HIV/AIDS, serious mental illness, developmental disabilities, and substance use conditions. Please
have one of the licensed health care professionals listed below complete the Home Stretch Disability
Verification to be considered for these specific housing opportunities.
• Acceptable Credentials for ANY Condition(s): MD (Medical Doctor), NP (Nurse Practitioner), PA
(Physician’s Assistant), DO (Doctor of Osteopathic Medicine)
• Acceptable Credentials for Mental Health & Substance Use Condition(s) ONLY: PsyD/ PhD
(Psychologist), LCSW (Licensed Clinical Social Worker), MFT/LMFT (Marriage and Family Therapist),
LPCC (Licensed Professional Clinical Counselor)
If a licensed health care professional CANNOT complete the disability verification, then disability can also be
verified by providing one of the documents listed below. However, it is strongly recommended that the Home
Stretch Disability Verification be completed, if possible.
Disability can also be verified by providing one of the documents listed below:
• Written verification of disability from the Social Security Administration, OR
• Copy of a disability check (e.g., Social Security Disability Insurance check or Veteran’s Disability
Compensation)
Email: HomeStretch@acgov.org | Phone: (510) 567-8017 | Fax: 1 (855) 658-5466
Revised 10/21/2025
Home Stretch Disability Verification
To Be Completed By A Licensed Health Care Professional
This verification will help prioritize homeless and disabled individuals for permanent supportive housing
opportunities in Alameda County.
This Disability Verification Form is for:
Patient Name:
Patient Date of Birth:
Clinician Contact Information:
Organization Name (if applicable):
Address:
Phone #:
E-mail:
I am a credentialed and licensed health care professional trained to perform diagnostic and functional assessments of
patients. Within my scope of practice, I have determined that the patient named above has the following diagnosable
condition(s) that are: 1) expected to be of long-continued and indefinite duration; AND 2) substantially impedes the
individual’s ability to live independently; AND 3) The condition could be improved by more suitable housing conditions.
(check ALL that apply):
Substance use disorder**
Serious mental illness, including severe Post Traumatic Stress Disorder (as defined in the DSM and is severe in
degree and persistent in duration; is NOT a substance use disorder, developmental disorder, or acquired
traumatic brain injury)**
Developmental disability (as defined in Section 102 of the Development Disabilities Assistance Bill of Rights Act
of 2000, {42 U.S.C. 15002})**
Cognitive impairments resulting from brain injury**
Chronic physical illness or disability*
HIV infection or AIDS*
*Acceptable Credentials for Any Conditions: MD (Medical Doctor), NP (Nurse Practitioner), PA (Physician’s Assistant), DO (Doctor of Osteopathic Medicine) **Acceptable Credentials for Mental Health & Substance Use Conditions ONLY: PsyD/ PhD (Psychologist), LCSW (Licensed Clinical Social Worker), MFT/LMFT
(Marriage and Family Therapist), LPCC (Licensed Professional Clinical Counselor)
My signature below serves as verification of the listed patient’s disability status, which is solely intended to facilitate
their prioritization for permanent supportive housing opportunities in Alameda County.
Intern Name, if applicable (printed):
Signature: Date:
Licensed Staff Name (printed):
Signature: Date:
Professional License Type: License #: