Residential Program Intake Form
Applicant's Information
Applicant's Name:
First Name
Last Name
Name and position of person filing out form (if different than applicant):
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Other Names Used:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number:
Please enter a valid phone number.
Have you recently experienced either of the following:
I am a recent victim/survivor of human trafficking.
I am a recent victim/survivor of domestic violence.
I do not have any history of trafficking or domestic violence.
Safe to leave message?:
Yes
No
Do you have a Driver's License?:
Yes
No
Is your License suspended?:
Yes
No
DL or ID #/ State:
Social Security Number:
Are you a U.S. Citizen?:
Yes
No
Are you eligible to work/go to school in the U.S.?:
Yes
No
Are you able to work/go to school at least 30 hours/week?:
Yes
No
Race:
White
African American
Hispanic
Asian/Pacific Islander
American Indian/Alaskan Native
Other
What is your preferred language?
English
Spanish
Other
Do you attend church?:
Yes
No
Church Name:
Person/resource referring you to our Residential Program:
If you do not have a referral, please mark "n/a"
Have you ever been a part of a residential program before?:
Yes
No
If yes, please include name of program, dates, and contact information:
Who is seeking housing?
Myself only
Myself and child(ren)
Please list names and ages of ALL applicants seeking housing:
Back
Next
Relationship and Family Information
Current Relationship Status:
Married
Never Married
Separated
Divorced
Reconciling
Widowed
Other
Maiden Name
First and Last Name of Current Partner:
Describe your relationship with your spouse/partner:
List previous marriages (Names and Dates):
Who do you feel is part of your support system?:
Describe your relationship with your parents:
Describe your relationship with your siblings and/or other family members:
Back
Next
Background Information
Have you ever received trauma focused therapeutic services?:
Yes
No
Please list details including provider and dates of service:
Have you ever had a psychological evaluation or a Comprehensive Clinical Assessment (CCA) completed?:
Yes
No
If so, when? And who was the provider?:
Have you ever been diagnosed with a mental illness?:
Yes
No
If yes, when and what was the diagnosis?:
Have you ever been hospitalized for a mental illness?:
Yes
No
If yes, please add dates and explanation:
Have you ever attempted suicide?:
Yes
No
If yes, when? Please elaborate.
Have you struggled with suicidal thoughts?:
Yes
No
Did you seek or receive treatment related to the suicidal attempt or thoughts?:
Yes
No
If yes, how recently?:
Do you or have you struggled with self-harm?:
Yes
No
If yes, how recently? What type?:
Have you used drugs in the past?:
Yes
No
If yes, what substances?:
If yes, within the last 90 days?:
Yes
No
If yes, what substances and how often?:
Have you had any alcohol in the past?:
Yes
No
If yes, within the last 90 days?:
Yes
No
If yes, how often?:
Have you ever received treatment (inpatient or outpatient) for substance abuse?:
Yes
No
If yes, when?:
Have you ever been physically or sexually abused?:
Yes
No
Please share any details you are willing to share:
Do you have any medical conditions? Please list.
What medications and supplements are you currently taking?:
Have you ever been convicted of a crime (Felony/Misdemeanor)?:
Yes
No
If yes, explain:
Are there any outstanding warrants, tickets or pending criminal charges against you?:
Yes
No
If yes, explain:
Are you on probation?:
Yes
No
If yes, explain:
Back
Next
Background Information Continued
List Previous Addresses (starting with most recent)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates at this residence:
Reason for moving:
Have you ever been evicted?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dates at this residence:
Reason for moving:
Character References
REFERENCES (Only use one personal resource (family member/friend) and one professional resource (therapist, physician, pastor, current program leader, probation officers, CPS workers, or case managers who you have current contact with.
Character Reference #1 Name:
First Name
Last Name
Relationship:
Phone Number:
Please enter a valid phone number.
Character Reference #2 Name:
First Name
Last Name
Relationship:
Phone Number:
Please enter a valid phone number.
Education
Grade in school completed:
Do you have a H.S. Diploma or GED?
Yes
No
Describe any job training or education you have completed:
Are you currently enrolled in an education program?:
Yes
No
If yes, where?:
Have you ever received a loan for educational purposes?
Yes
No
If yes, please list:
Are you in default on any of these loans listed?
Yes
No
Please explain:
Do you have any outstanding debt (credit cards, loans, etc.)
Yes
No
What is your total debt?:
Back
Next
Transportation
Do you have a car?
Yes
No
Year/Make/Model:
Color:
License plate #:
Insurance Company:
Value: $
Running condition:
If you do not have a car, what are your plans for transportation?:
Back
Next
Work History
(List employment beginning with most recent.)
Business Name:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Supervisor:
Dates Employed:
Position(s) Held:
Hourly Wage:
Monthly Pay:
Reason for Leaving:
Other work history (please list name of business, dates, and reason for leaving) to give a full picture:
Back
Next
Children's Information
Do you have children that would also need housing?
Please Select
Yes
No
Child #1 Name:
First Name
Last Name
Social Security Number:
Immunization Records:
Yes
No
Gender:
Male
Female
Grade & School:
What are the child custody/visitation arrangements? (if any):
Has this child ever received counseling?
Yes, but not currently.
No.
Yes, and is currently still in counseling.
Has he/she ever had a psychological evaluation?
Yes
No
Outcome:
Does he/she use drugs or alcohol?
Yes
No
Please explain:
Has he/she used drugs or alcohol before?
Yes
No
Comments:
Does he/she use tobacco products?
Yes
No
Has he/she ever been physically or sexually abused?
Yes
No
Comments:
What medications is he/she on?
What hospitalizations has he/she had?
Has he/she ever been convicted of a crime?
Yes
No
If so, please explain:
Is he/she on probation or in any legal trouble?:
Yes
No
If so, please explain:
Do you need to add more children to the application?
Please Select
Yes
No
Back
Next
Child #2 Name
First Name
Last Name
Social Security Number:
Immunization Records:
Yes
No
Gender:
Male
Female
Grade & School:
What are the child custody/visitation arrangements? (if any):
Has this child ever received counseling?
Yes, but not currently.
No.
Yes, and is currently still in counseling.
Has he/she ever had a psychological evaluation?
Yes
No
Outcome:
Does he/she use drugs or alcohol?
Yes
No
Please explain:
Has he/she used drugs or alcohol before?
Yes
No
Comments:
Does he/she use tobacco products?
Yes
No
Has he/she ever been physically or sexually abused?
Yes
No
Comments:
What medications is he/she on?
What hospitalizations has he/she had?
Has he/she ever been convicted of a crime?
Yes
No
If so, please explain:
Is he/she on probation or in any legal trouble?:
Yes
No
If so, please explain:
Do you need to add more children to this application?
Please Select
Yes
No
Child #3 Name
First Name
Last Name
Social Security Number:
Immunization Records:
Yes
No
Gender:
Male
Female
Grade & School:
What are the child custody/visitation arrangements? (if any):
Has this child ever received counseling?
Yes, but not currently.
No.
Yes, and is currently still in counseling.
Has he/she ever had a psychological evaluation?
Yes
No
Outcome:
Does he/she use drugs or alcohol?
Yes
No
Please explain:
Has he/she used drugs or alcohol before?
Yes
No
Comments:
Does he/she use tobacco products?
Yes
No
Has he/she ever been physically or sexually abused?
Yes
No
Comments:
What medications is he/she on?
What hospitalizations has he/she had?
Has he/she ever been convicted of a crime?
Yes
No
If so, please explain:
Is he/she on probation or in any legal trouble?:
Yes
No
If so, please explain:
Do you need to add more children to this application?
Please Select
Yes
No
Child #4 Name
First Name
Last Name
Social Security Number:
Immunization Records:
Yes
No
Gender:
Male
Female
Grade & School:
What are the child custody/visitation arrangements? (if any):
Has this child ever received counseling?
Yes, but not currently.
No.
Yes, and is currently still in counseling.
Has he/she ever had a psychological evaluation?
Yes
No
Outcome:
Does he/she use drugs or alcohol?
Yes
No
Please explain:
Has he/she used drugs or alcohol before?
Yes
No
Comments:
Does he/she use tobacco products?
Yes
No
Has he/she ever been physically or sexually abused?
Yes
No
Comments:
What medications is he/she on?
What hospitalizations has he/she had?
Has he/she ever been convicted of a crime?
Yes
No
If so, please explain:
Is he/she on probation or in any legal trouble?:
Yes
No
If so, please explain:
Back
Next
Parent/Child Status
Explain you/ your family's current circumstances and your needs:
What do you want to accomplish by moving to The Lantern Residential Program?:
Are you pregnant?:
Yes
No
Do you have any children not listed above?
Yes
No
Does CPS have custody of any of your children?
Yes
No
If yes, please explain:
Are you or have you been involved with CPS?:
Yes
No
Describe how your children get along with friends/teachers at school:
Describe your children's personality and behavior:
Describe your relationship with your children:
How do your children feel about the idea of coming into The Lantern Residential Program?:
Other comments about your children:
Agreement
The information contained in the application is correct to the best of my knowledge. I understand that making false statements or being untruthful at any time will result in termination of The Lantern Residential Program.
Signature
Submit
Should be Empty: