PERSONAL HISTORY. Name: First Middle Last Mailing Address: Phone # ( ) - Can we leave you a detailed message at this number?

Transcription

1 Please fax application to: If you have any questions: Katherine s House Gretchen Marshall Rita s House Jo Cherland PERSONAL HISTORY Name: First Middle Last Mailing Address: Phone # ( ) - Can we leave you a detailed message at this number? yes no address: Birthdate: / / Age: Gender: Social Security Number (optional): / / Sobriety Date: Are you Hispanic? yes no Ethnicity: Black/African American White/Caucasian Asian American Indian/Alaskan Native Native Hawaiian/Pacific Islander other (specify) Were you born in the U. S.? yes no Military Service? yes no If yes, when did you serve? before Vietnam Vietnam era Post Vietnam ( ) Persian Gulf era (1991-present) What branch of the military? Army Air Force Marines Navy Other Did you serve in a war zone? yes no How were you discharged? Honorable General Medical Bad Conduct Dishonorable Not Discharged Are you the spouse of a veteran or member of the military? yes no Where did you hear about Katherine s/rita s House? (The above questions are for record keeping purposes only, and will not be a consideration in determining an applicant s eligibility for acceptance to Katherine s/rita s House).

2 Relative emergency contact This is required. At least one emergency contact should be a relative, they do not have to be in Washington. 1. Name: Relationship: Address: City/State/Zip Code: Telephone Number: 2. Name: Relationship: Address: City/State/Zip Code: Telephone Number: Income and Employment and Education (fill out across unless you check no income ) Sources of Income (check all that apply) Amount per month? When did you start receiving this income? When will you stop receiving this income? Work $ Unemployment Benefits $ GAU or GAX $ SSI or SSDI $ Social Security $ ADATSA $ Veterans Benefits $ TANF $ Other (not food stamps) $ No income Are you currently receiving any of the following? (please check all that apply): Food Stamps Medicaid Medicare WorkSource Veterans Health Care Estimated income for the last 12 months: How much money do you have saved right now? Do you have a Protective Payee (someone else who handles your money)? yes no If yes, name/agency Phone: Employment Current employer: Employer phone: Is this job? Full-time Part-time On-call Is this job? Permanent Temporary Seasonal How many hours per week? Pay: $ (circle one) per month/week/day

3 Date this job started: Can you provide proof/pay stubs? yes no When was the last time you worked full time? When was the last time you worked part time or day labor? Are you looking for work? Occupation Are you in a job search program? yes no If yes, which one? List your job skills: (do not omit such things as cooking, cleaning, repair work, etc.) Education Are you currently in school working on any degree or certificate? yes no If so, what is the program? Have you received vocation training or apprenticeship certificates? yes no What is the highest level of school you have completed? nursery school to 4 th 11 th grade Associates Degree grade 5 th or 6 th grade 12 th grade (no diploma) Bachelors Degree 7 th or 8 th grade high school diploma Masters Degree 9 th grade GED Doctorate 10 th grade Some College (no degree or certificate) Other graduate/professional degree/certificate (please list) Did you ever take special education classes in school? yes no Have you ever received services or benefits for a developmental disability? yes no If yes, please explain Health Disability Are you disabled? yes no If yes, please describe your disability (if you receive GAU or SSI please list the disability which qualified you to receive that income): Physical Health How would you describe your general physical health? excellent good fair poor

4 Do you currently have a medical doctor? yes no If yes, where (what clinic or hospital?) Doctor s name Phone How often do you see them? Are you currently pregnant? yes no If yes, when is your due date? Do you smoke? yes no Katherine s/rita s House can help with quitting smoking. Do you want to discuss quitting smoking? yes no Hospitalization History (use additional paper if necessary) Date entered Date left Reason for hospitalization Location/Hospital Type of treatment Are you currently taking any medications prescribed by a doctor? yes no Prescribed Medications (use additional paper if necessary) Name of medication What is the medication for? Who prescribes it? Are you allergic to any medications? yes no If yes, what? Mental Health Have you ever been treated for mental illness? yes no If yes, when was the last time? Have you ever been hospitalized for mental illness? yes no If yes, when was the last time?

5 Do you currently have a counselor or therapist? yes no If yes, where (what agency?) Name Phone How often do you see them? Mental Health Treatment History (use additional paper if necessary) Date Began Date Ended Reason for Treatment Location/Agency Type of Treatment D. Drugs and Alcohol Have you ever been diagnosed as drug dependent? yes no Have you ever been diagnosed as alcohol dependent? yes no Have drugs or alcohol ever been a problem in your life? yes no Please explain: Are you now or have you been in treatment? yes no Drug and Alcohol Treatment History (use additional paper if necessary) Date began Date ended Reason for treatment Location/Program Type of treatment Inpatient/outpatient F. Gambling Have your gambling habits ever caused problems in your life (ex. money problems, relationship issues, trouble paying for housing)? yes no

6 Have you ever thought you had a problem with gambling? yes no Have you ever or do you now attended Gambler s Anonymous? yes no If yes, when and where? E. Prior Housing When did you become homeless? month/date/year / / Where was the last place you had stable housing? City State Zip How long did you live there? Have you been homeless/without a place to stay for the past 12 months or more? yes no In the past three years, have you been homeless four or more times? yes no Have you ever been barred or asked to leave any shelter? yes no If yes, explain the circumstances (when/what shelter/why?): Have you ever been evicted from somewhere you were living? yes no If yes, explain the circumstances (when/where/why): H. Domestic violence/abuse Has Domestic Violence affected your life? yes no If yes, please explain how and when I. Legal We will confirm this information with the Washington State Patrol. A criminal history does not automatically disqualify you from living at Katherine s/rita s House. A dishonest answer does. If any convictions are on your record that you don't admit to on this application, you will not be accepted into the program. Are you presently under a no-contact order? yes no

7 If yes, name of person Relationship Please explain what happened When is the last time you saw this person? Have you ever been arrested for a criminal offense, including misdemeanors? yes no If yes, please list below. Do you have any pending criminal court appearances? yes no Are you currently on probation or parole? yes no If yes, probation officer s name contact # Describe the conditions of your release? (fines, classes, community services, reporting, etc.) Criminal History (You must list all arrests regardless of their outcome- use additional paper if necessary. Failure to list an arrest will result in an automatic denial of your application) Date (month year) Offense committed Location: City/State Result: fine/conviction/ amount of time served Signature Date