Personal Information Form

Personal Information Form

Burfoot House | Program for Homeless Women
Todays Date*

MonthDayYear
Date
First Name*
Middle Name
Last Name*
Social Security Number*
What other names are you known by?*
Date of Birth*

MonthDayYear
Date
Your Age*
City/Residence/Benefits*
Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Marital Status (check one):*

SingleMarriedCo-habituatingSeparatedWidowedDivorced
Do you have an ID?

YesNo
If Yes what type of ID?
ID Card Expiration Date:

MonthDayYear
Date
Ethnicity:*

HispanicNon-Hispanic
Race:*

American Indian or Native AlaskanNative Hawaiian or other Pacific IslanderAsianBlackWhiteOther
Religion:

ChristianCatholicJewishMuslimOther
Education (check one):

Jr. High SchoolGEDJr. College, A.A/A.S.High School GradSome CollageCollege Grad, B.A./B.S.Grad School M.A./M.S.Doctorate/Professional
Are you currently in school?

YesNo
If yes, what type of program?
If yes, where did you attent?
Are you currently in vocational training?

YesNo
If Yes what type of program?
If Yes where did you attent?
Last Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Please enter a valid phone number.
What describes your last address? (Check all that apply):

Rental House or ApartmentRelative or FriendHotel or MotelPaid for Public HousingHospital (Non-Psychiatric) w/o Emergency VoucherSection 8Foster Care Home or Foster Care GroupShelter Plus CareEmergency ShelterSubsidized HousingTransitional Housing for Homeless PersonsPlace not meant for habitation (vehicle, streets, abandoned building, etc.)HomeownershipPermanent Housing for Formerly Homeless PersonsPsychiatric FacilitySubstance Abuse Treatment or Other Detox CenterJail, Prison or Juvenile Detention CenterOther
Providers:
Veterans’ Affairs Contact Person:
Veterans’ Affairs Contact Phone:
Please enter a valid phone number.
Case Manager:
Case Manager City:
Case Manager Phone:
Please enter a valid phone number.
Probation/Parole Contact Person:
Probation/Parole Contact Phone:
Please enter a valid phone number.
Counseling Contact Person:
Counseling Contact Person Phone:
Please enter a valid phone number.
Other City Contacts:
Other City Contacts Phone:
Please enter a valid phone number.
Military Service: (Please skip section if not relevant)
Are you a military veteran?

YesNo
If yes, please respond to the following questions:
Length of time served on active duty:
Military Branch?
Type of Discharge:
Did you serve in a war zone?

YesNo
Do you have a military service-related disability?

YesNo
If yes, explain:
Are you receiving veterans’ services or benefits?

YesNo
If No, explain:
Insurance:
Which best describes your insurance situation?

Blue CrossHMOVA InsuranceObama CareFAMISOptimaMedicaidPrivateAetnaMedicareNoneOther
Criminal Record:
Do you currently have any charges pending against you?

YesNo
If Yes, the charge Stage: Court Date: Date
Have you ever been charged with a felony?

YesNo
If Yes, the charge State: Time Served
Are you currently on probation or parole?

YesNo
If Yes how long? State: PO's Name
Do you have any misdemeanor charges?

YesNo
If yes, explain:
Do you have any remaining time left to serve?

YesNo
If yes, how long? If yes, when? If yes, where?
Do you have any pending criminal charges?

YesNo
Income

Type of income:

	How much? (proof)	How often? (weekly, monthly, etc.)
Employed/Earned Income
SNAP
TANF
Pension
SSA
SSDI
SSI
Unemployment
Veterans
General Assistance
Workman's Compensation
Child Support
Alimony
Other including solicitation income

Why are you homeless?

UnknownLost BenefitsFinancialRoommate ProblemsLegal ProblemsUnemployedAddictionsDomestic ProblemsEvictionMental HealthMedical ProblemsRelocationFirst TimeJail/PrisonChronic Homelessness
How long have you been homeless?

Unknown> 1 week2 -3 weeks1 month2-3 months4 – 5 months6 months1 year1-2 years2-3 years3-4 years4+ years
What is your current health status?

ExcellentVery GoodGoodFairPoorDon't Know
Are you pregnant?

YesNo
If yes, due date?

MonthDayYear
Date
Please answer yes/no to indicate if you have or have had the following:
HIV/AIDS

YesNo
Mental Health Issues

YesNo
Substance Abuse

YesNo
Domestic Violence

YesNo
If you have experienced domestic violence, please indicate the most accurate time frame:

Within 3 months ago3 – 6 months ago6 – 12 months agoMore than a year agoDon’t knowRefused
Mental Health
Diagnosis blanks Are you currently receiving counseling? blank Are you currently taking medications?
Diagnosis blanks Are you currently receiving counseling? blank Are you currently taking medications?
Diagnosis blanks Are you currently receiving counseling? blank Are you currently taking medications?
Addiction History (check all that apply):

AlcoholGamblingSelf-abuseSexual AddictionsCocaineLSDInhalantsMarijuanaOpiumNarcoticsPsychotropicAmphetamineHeroinSedativesOther
Transportation/Vehicle Information:
What is your means of transportation?

WalkBusTaxiOther
Do you have a valid driver’s license?

YesNo
If no, what is needed to obtain a valid driver’s license?
Driver’s License Number: blanks Expiration Date
Do you own a car?

YesNo
Do you have financial responsibility for a car loan?

YesNo
Will you be using the car while at the Burfoot House?

YesNo
Vehicle Make: Model: Year:
License Plate: Color:
Is your car legally registered? (Verify)

YesNo
No If so, in what state?
Is your car drivable?

YesNo
Is your car insured? (Verify)

YesNo
Auto Insurance Provider: Insurance Number:
Emergency Contact:
First Name
Last Name
Relation to contact:
Contact Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number
Please enter a valid phone number.
Contact Type:

FamilyLegal/MedicalCase WorkerProbation Officer
Intake Summary
Signature

Clear
Date*

MonthDayYear
Date
Should be Empty: