Vision For Life
5577 Eureka Drive, Fairfield Twp, OH, 45011
connect@vflhomes.org
www.vflhomes.org
(513) 817-1642
V.F.L PARTICIPATENT Application:
Please note if you are a case manager please fill this out on behalf of your client to the best of your ability
How did you hear about us?
*
Please Select
Email
Phone Call
In-Person
Google
Other
Please Specify
*
Full Name
*
First Name
Last Name
Last Recent Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Best E-mail
example@example.com
Date Of Birth
-
Month
-
Day
Year
DOB
What is your anticipated move-in date?
-
Month
-
Day
Year
Date Of Birth
Sexual Orientation
Please Select
heterosexual (straight)
bisexual
homosexual
Trans
What were you born as?
Gender
Please Select
Male
Female
What were you born as?
Marital Status
Please Select
Single
Married
Separated
Divorced
What were you born as?
Do you have any dependents?
Yes
No
In Progress
Are you currently employed?
Please Select
Yes
No
Never Been Employed
What were you born as?
If currently working, what is your monthly current salary?
Please Select
Up to $2500
$2500 - $3500
Over $3500
What were you born as?
When Were You Last Employed?
-
Month
-
Day
Year
Last Employment Date
What Is Your Job Status?
Part-Time (Less Than 35/hrs)
Full-Time (+35/hrs)
Currently Not Employed
Tell us about your last or most recent employment. (It can be paid or unpaid work) Also how long did you work there?:
What other means of support do you have? (Check all that apply)
None
State Assistance (i.e. Food or Income Support)
Social Security
Disability
Unemployment
Alimony
Child Support
Family
Other
Highest Education Status
Please Select
High School Diploma
GED
Some College
College Degree
Other (Trade. etc.)
What were you born as?
What is your legal status? / Do You Have Any Legal Concerns?
Please Select
No Legal Status
On Probation - Formal
Summary Probation - Informal
On Parole
Case Pending Not Determined Yet
What were you born as?
List the name of your probation or parole officer and department location (if applicable)
Do you or have you ever struggled with substance abuse?
Yes
No
Are you in recovery?
Yes
No
Have you received substance abuse treatment?
No
Yes
Currently In Treatment
Are you currently taking prescription medication?
Yes
No
List the prescriptions you are currently taking, why you are taking them, and your prescribing doctor.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Phone Number
*
Format: (000) 000-0000.
Please give reference of any two people whom you feel:
Rows
Full Name
Address
Contact Number
Relationship
1
2
Submit
Should be Empty: