Application to stay at Grace Place 10/11

Transcription

1 Intake done by: Applicant Information: Application to stay at Grace Place 10/11 First Name: M.I. Last Name: SSN: DOB: Indicate any other last name you may have received services from the Salvation Army under: Gender Male Race(s) White Ethnicity Hispanic/Latino Female Asian Other (Non-Hispanic/Latino Transgender Other Don t know Unknown Other Multi-Racial Refused Don t know Refused Black or African American Am. Indian or Alaskan Islander Don t know Refused Last Permanent Address: Address: City: State: Zip: Phone number: County: Are you homeless? Yes No Have you had at least 4 episodes of homelessness in the past 3 years with a disabling condition who has either been continuously homeless for a year or more? Yes No Housing Status: Literally Homeless Housed & at imminent risk of losing housing Housed & at risk of losing housing Stably housed Don t know Refused Type of living situation: Rental by client, no housing subsidy Owned by client, no housing subsidy Motel/Hotel paid for with out emergency shelter money Staying or living in a family members room, apartment or house Staying or living in a friend s room, apartment or house Rental by client with VASH housing subsidy Jail, prison or juvenile detention facility Substance abuse treatment facility or detox center Permanent housing for formerly homeless persons (such as AHP, S&C, or SRO Mod Rehab) Psychiatric hospital or other psychiatric facility 1

2 Hospital (non-psychiatric) Foster care home or foster care group home Don t know Refused Transitional living for homeless (including homeless youth) Place not meant for habitation inclusive of non-housing service site (outreach programs only) Save haven Your length of stay at that residence: One week or less More than one week but less than one month One to three months Refused More than three months but less than one year One year or longer Don t know Reason you left that situation? Zip code of the last place permanent residence (or check) Don t know Family and Background Information: The Following Questions Are Used To Determine Information About Your Annual Income. Answer the following questions: How Many Individuals are in your Household? What is Your Household's Monthly Income? or check Don't know Refused Are you a US Military Veteran? Yes No Don't know Refused Do You have a Disability? Yes No Don't know Refused Does anyone else in your household have a disability? Yes No Don't know Refused Please indicate who has the disability, and enter start/end date only if you know the date the disability began/ended (mo/day/yr) Check Start/End date check Who Start/End date Alcohol Abuse / Hearing Impaired / Drug Abuse / Vision Impaired / Developmental / Other / Physical/Medical / Other Alzheimer s/dementia / Physical / Other Cognitive / Mental Health Problem / Other Learning / Dual diagnosis / Other Mental Handicap/Injury / HIV/AIDS / Other Speech / Both Alcohol & Drug Abuse / Disability Determination Yes No Don t know Refused (If yes) Currently receiving services or treatment: Yes No Don t know Refused 2

3 Do you smoke? Yes No Don t know Refused If you smoke, have you thought about quitting? Yes No Don t know Refused IF you smoke, would you accept a referral for treatment? Yes No Don t know Refused Does anyone else in hour household smoke? Yes No Don t know Refused Who Adult Youth Income received from any source last 30 days Last 30 day income $ Source of income A Veteran s Disability Payment Retirement Income from Social Security Alimony or Other Spousal Support SSDI Child Support SSI Earned Income TANF General Assistance Unemployment Insurance No Financial Resources Workers Compensation Pension from a former job Private Disability Insurance Receiving Income Source Yes No Start Date / / End Date / / Non cash benefit received in last 30 days Amount of Non Cash Benefit Source of Non-Cash Benefit Food Stamps Medicaid Medicare SCHIP WIC VA Medical Services $ TANF Child Care Services TANF Transportation Services TANF-Funded Services Section 8, Public Housing or Rental Assistance Source If Other, Please Specify Receiving Benefit: Yes No Start Date / / End Date / / 3

4 Employment Information: Are your currently employed? Yes No If unemployed what is current status? Unemployed seeking work Student Unemployed not seeking work Not job ready or employable If employed is your position? Full-time Part-time If employed type of employment: Seasonal Permanent Temporary Where are you working? Education: Highest level of school completed: (last grade completed) Do you have a: Diploma GED HSED Tech School or College degree Military Service: Are you a US Military Veteran? Yes No Peace Time service only? Yes No Income and Benefits Information: Please indicate amount received each month: Wages: Social Security: Unemployment: SSI: W-2: Child support: : Please list your monthly bills: Please indicate amounts due: Rent/Mortgage: Transportation: Phone: Heat: Electric: Childcare: Credit Cards: Medical: Fines: Court assessed fees: What type of assistance have you received or applied for in the last 6 months? (check all that apply) W-2: Food Pantry: Medical Asst: SSI: WIC: Childcare: Food stamps: Energy Asst: Rent Asst: WestCap: Rural Housing: Other: Transportation Information: Do you have a vehicle? Yes No Make: Model: Year: License Plate #: Do you have a Drivers license? Yes No DL#: State issued: Is your license currently valid? Yes No Criminal History: Do you have a criminal history? Yes No (If yes please explain.) Have you ever been convicted of a sex crime? Yes No Do you have a restraining order? Yes No Are you currently or have you ever been on probation or parole? Yes No 4

5 If yes, please explain: Parole/Probation Officer: If yes, provide phone number here: Personal References: (Please list three relatives below that we have permission to contact) 1. Name: Telephone Number: Address: Relationship: 2. Name: Telephone Number: Address: Relationship: 3. Name: Telephone Number: Address: Relationship: What is your household type: Female single parent Male single parent Couple and child(ren) Minor and child(ren) Couple without child(ren) (Check One) Related caregiver Unrelated caregiver Extended Family Are you the head of your household? (Check One) Yes No What is your relationship in the household? Who is the head of your household? I, the undersigned, do hereby acknowledge that all information given is true and factual and that any misrepresentation may lead to eviction from the Grace Place: Signature of Head of Household Date Signature of Person Legally Authorized to Consent Relationship Date 5

6 NAMES OF OTHER ADULTS IN THE HOUSEHOLD: Social Security # - - or check don t know or don t have refused Date of Birth Race(s) Am. Indian or Alaskan Native Gender Male Native Hawaiian or other Pacific Islander Female Asian Transgender Relationship to Head of Household White US Military Veteran? Yes No Multi-Racial (Non-hispanic/Latino) Income in last 30 days? Source of income? Receiving income? Yes No Start Date / / End Date / / 6

7 NAMES OF MINORS IN THE HOUSEHOLD: Social Security # - - or check don t know or don t have refused Date of Birth Race(s) Am. Indian or Alaskan Native Gender Male Native Hawaiian or other Pacific Islander Female Asian Transgender Relationship to Head of Household White Multi-Racial (Non-Hispanic/Latino) NAMES OF ADDITIONAL MINORS IN THE HOUSEHOLD: Social Security # - - or check don t know or don t have refused Date of Birth Race(s) Am.Indian or Alaskan Native Gender Male Native Hawaiian or other Pacific Islander Female Asian Transgender Relationship to Head of Household White Multi-Racial (Non-hispanic/Latino) 7

8 NAMES OF ADDITIONAL MINORS IN THE HOUSEHOLD: Social Security # - - or check don t know or don t have refused Date of Birth Race(s) Am.Indian or Alaskan Native Gender Male Native Hawaiian or other Pacific Islander Female Asian Transgender Relationship to Head of Household White Multi-Racial (Non-hispanic/Latino) NAMES OF ADDITIONAL MINORS IN THE HOUSEHOLD: Social Security # - - or check don t know or don t have refused Date of Birth Race(s) Am.Indian or Alaskan Native Gender Male Native Hawaiian or other Pacific Islander Female Asia Transgender Relationship to Head of Household White Multi-Racial (Non-hispanic/Latino) Staff/Residents/Resident Intake/Resident Intake Forms Revised10/11 8

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