Further Consolidated Clone of Consolidated Application for Homeless Housing
MKII 9/23/23
Personal Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Race
Asian
African American
Caucasian
Hispanic
Native American/Pacific Islander
Social Security Number
Marital Status
Single
Divorced
Married
Separated
Widowed
Most Recent Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Do You Have a GA ID or Driver's License?
Yes
No
GA ID/License Number
Are You a Veteran?
Yes
No
Current Situation
Describe your prior living situation:
Have you ever been treated, or are you in need of treatment for a Physical Disability
Current Treatment
Previous Treatment
Need Treatment
No
Have you ever been treated, or are you in need of treatment for Mental Illness
Current Treatment
Previous Treatment
Need Treatment
No
Have you ever been treated, or are you in need of treatment for Drug Abuse
Current Treatment
Previous Treatment
Need Treatment
No
Have you ever been treated, or are you in need of treatment for Alcoholism
Current Treatment
Previous Treatment
Need Treatment
No
Drug(s) of Choice - Check All That Apply
Opioids
Cocaine
Amphetamine/Methamphetamine
Benzodiazapenes
Alcohol
Marijuana
Other
Describe Other
Date Of Last Use
-
Month
-
Day
Year
Date
Describe how you came to use drugs or alcohol and any past treatment history:
Medical And Mental Health Treatment History
Are you under the care of a medical doctor?
Yes
No
What medical condition are you being treated for?
Name and phone number of your medical doctor:
Describe any physical limitations due to a medical condition
Have you ever received, or are you currently receiving, mental health counseling or treatment?
Yes
No
Diagnosis
When and where were you last treated?
Have you ever attempted suicide? If yes, describe the situation.
Have you ever attempted homicide? If yes, describe the situation.
Are you taking any prescribed medications? Describe: medication, dosage, frequency.
Legal Circumstances
Are you currently on Probation/Parole?
Yes
No
Probation/Parole Officer's Name
County Overseeing Probation/Parole
Probation/Parole Officer's Phone Number
Please enter a valid phone number.
What were your original charges?
What is your reporting status?
Fines/Fees?
Pending Court Date(s)
Income and Work History
Current or Previous Employer
Address
Phone Number
Please enter a valid phone number.
From
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Title/Duties
Hours Worked Weekly
Hourly Rate or Salary
Income at Entry
Do you have any other sources of income?
Yes
No
TANF
$1-$150
$151-$250
$251-$500
$501-$1000
$1001-$1500
$1501-$2000
$2001 plus
SSI/SSD
$1-$150
$151-$250
$251-$500
$501-$1000
$1001-$1500
$1501-$2000
$2001 plus
Child Support/Alimony
$1-$150
$151-$250
$251-$500
$501-$1000
$1001-$1500
$1501-$2000
$2001 plus
Unemployment
$1-$150
$151-$250
$251-$500
$501-$1000
$1001-$1500
$1501-$2000
$2001 plus
Food Stamps
$1-$150
$151-$250
$251-$500
$501-$1000
$1001-$1500
$1501-$2000
$2001 plus
Why are you applying for this scholarship? What do you hope to achieve and what strengths do you believe that you have that may help you achieve this?
Release of Information Authorization
CLIENT'S FULL NAME
First Name
Last Name
CLIENT'S DATE OF BIRTH
-
Month
-
Day
Year
Date
PROTECTED HEALTH INFORMATION (PHI) TO BE OBTAINED FROM OR DISLCOSED TO:
PROTECTED HEALTH INFORMATION (PHI) TO BE OBTAINED FROM OR DISLCOSED TO:
I hereby grant permission to the 4Recovery Foundation to obtain, share or release any and all of my personal and/or medical records for the purposes of qualification and/or enrollment in this program.
I hereby grant permission to the 4Recovery Foundation to obtain, share or release any and all of my personal and/or medical records for the purposes of qualification and/or enrollment in this program.
Signature
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