Angels Over Cliff's Phone Assessment Application

Date

Volunteer Name

Applicant’s General Information:

Applicant's Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Birth Date and Age

Gender: Male or Female

Are you LGBTQIA ?

Email

example@example.com

Spouses Name

First NameLast Name

Birth Date and Age

Phone Number

Please enter a valid phone number.

Current Address (where you receive mail):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Where do you sleep at night right now?

How long have you been homeless? Explain briefly, what caused you to become homeless?

What is your previous address? How long were you there? Explain why you left?

What is your Race?

Are you a Native American?

Are you a US Citizen?

If you are not a US Citizen, then are you documented? If not, then when do you plan on obtaining your citizenship?

Do you have a Driver's License or California ID ?

What is the address on your Driver’s License or Calif ID:

Do you have a Car? Does it run well?

Car Make, Model and Year:

Employment & Education information

Are you currently Employed:

Position Held:

Employer Name:

Dates from/to:

Monthly Gross Income:

Are you currently enrolled with or working with any other agencies or organizations for help?

Do you or anyone in your family receive any public assistance benefits?(Cal Fresh, Cal Works, Cash Aid, Medi-Cal, SSI, SSDI)?

What Income do you have coming in?

Total Amount receiving?

Are you a Veteran?

Are you receiving any VA benefits? If so, what is the Amount?

Are you working with any agencies that help Veterans?

What is your total monthly income altogether for the entire family?

What are your current monthly bills, please list below:

Bill #1:

Amount:

Bill #2:

Amount:

Bill #3:

Amount:

Total spent on monthly bills:

How much can you afford in monthly rent?

Do you have a Section 8 voucher?

Are you on the Section 8 housing waiting list?

Do you have any evictions? If so, explain why?

What is your Credit Score? Good, Fair, Poor?

What is your Highest Level of Education?

Are you currently in school?

If you have children living with you, then we need the following information for each child:

Do you and/or everyone in your family have a Social Security Card and Birth Certificate? If not, please explain why you do not?

Information for Child #1:

First NameLast Name

For Child #1: Please provide DOB#, Age, Grade and Gender. And if they have any Health concerns.

What school do they attend? And in what City?

Information for Child #2:

First NameLast Name

For Child #2: Please provide DOB#, Age, Grade and Gender. And if they have any Health concerns.

What school do they attend? And in what City?

Information for Child #3:

First NameLast Name

For Child #3: Please provide DOB#, Age, Grade and Gender. And if they have any Health concerns.

What school do they attend? And in what City?

Information for Child #4:

First NameLast Name

For Child #4: Please provide DOB#, Age, Grade and Gender. And if they have any Health concerns.

What school do they attend? And in what City?

Do you or anyone in your family have any Health concerns? Do you or anyone in your family have HIV?

Are you or is anyone in your family pregnant? If so, what is the Due date?

Are you a victim of domestic violence? If so, please provide brief details:

Do you have family you keep in touch with, and if so, what do those relationships look like?

Please provide your Emergency Contact Information:

Pet Information:

Do you have any pets? If so, how many? And what kind?

Are your pets sprayed or neutered? Are they current on their vaccines?

Criminal Background Information:

Have you ever been arrested for a Criminal Charge? If so, please provide brief details:

Are you a felon?

Are you on Parole? If so, when does your parole end?

Have you been convicted of a misdemeanor? If so, please provide brief details:

Are you currently on probation? If so, how long?

Health and Drug Addiction Information:

Do you have any Medical Health concerns?

Are you or anyone in your family suicidal or depressed?

Are you currently battling any drug or alcohol additions? Explain your addiction.

(Note: This will not prevent you from receiving help).

Are you currently taking any medication? If yes, what are they?

Have you been diagnosed or ever been hospitalized for any Mental Health reasons? If yes, give approximate dates and explain.

Has anyone in your family been diagnosed with Mental Health conditions or been hospitalized? If yes, please explain.