AUTHORIZATION TO HOLD HOUSE KEY

_____________________________________________________

(Name of Individual)

I understand that certain staff may have a need to enter my apartment in case of emergency or for other reasons. To be able to do this, I authorize the following staff to retain a key to my home. I do this with full knowledge of and agreement with what this may entail.

Staff Name(s) with authorization to hold a house key:

____________________________________________________

____________________________________________________

____________________________________________________

Go over the information with the individual on Intake, obtain signatures and submit to the Program Administrator. For Annual and Quarterly Reviews, use this information for reference only and have the client sign the Topics form as proof the client received this information. Provide a copy if the client wants one.
Individual	Signature	Date
Individual
Guardian/Representative
Staff