Application for Services
Welcome to Adullam Alabama.
This assessment, is how people experiencing or at risk of experiencing homelessness can apply for assistance. After your application is submitted, your answers will be reviewed by a case manager to determine your eligibility for services. A case manager will contact you to go over your application and guide you in your next steps to receive assistance. Please contact us with any questions you may have at services@adullamalabama.org.
Who is completing this application?
I am
*
Applying for services for myself
Applying for services for a friend or family member
If applying for someone other than yourself, why are you applying for them?
They are unable to do so because they do not have access to a computer or phone
They are currently incarcerated
Client Profile
Your Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Alias or Nickname
Email
example@example.com
Phone Number
Format: (000) 000-0000.
May We leave a message at this number?
Yes
No
Social Security Number
*
XXX-XX-XXXX
Are you a US Military Veteran?
Please Select
Yes
No
Gender
Please Select
Male
Female
A gender other than singularly female or male (e.g., non-binary, genderfluid, agender, culturally specific gender)
Transgender
Questioning
Primary Race
Please Select
American Indian
Alaska Native
Indigenous
Asian
Asian American
Black
African American or African Native
Hawaiian or Pacific Islander
White
Have you been recently released from Prison or Jail?
Please Select
Yes
No
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Next
Submit
What is Your Situation?
Type of Need
Please Select
I am Homeless
I am about to be Homeless
What is your current living situation?
Please Select
Place not meant for habitation (tent, woods, other outdoor situation)
Emergency Shelter (including hotel or motel paid for with voucher)
Hospital or other residential non-psychiatric medical facility
Jail, prison
Long-term care facility or nursing home
Psychiatric hospital or other psychiatric facility
Substance abuse treatment facility or detox center
Residential project or halfway house with no homeless criteria
Hotel or motel paid for without emergency shelter voucher
Transition Housing Host Home (non-crisis)
Staying or living with a friend
Staying or living with a family member
Rental by you, with housing subsidy
Rental by you
Owned by you
Other
When is your current living situation due to end?
Please Select
It has already ended
Within 7 days
Within 14 days
Within 30 days
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Medical
Do you have a disabling condition?
Please Select
Yes
No
Do you suffer from any of the following?
Please Select
Alcohol Use Disorder
Both Alcohol and Drug Use Disorder
Chronic Health Condition
Developmental
Drug Use Disorder
HIV / AIDS
Mental Health Disorder
None of the above
Are you covered under any health insurance?
Please Select
Yes
No
Select all insurance you are covered by
Medicaid
Medicare
Veteran's Administration (VA) Medical Services
Employer Provided
Cobra
Private Pay State Health Insurance for Adults
Indian Health Services Program
Other
I am not Insured
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Housing
Where did you stay last night?
Please Select
Place not meant for habitation (tent, woods, other outdoor situation)
Emergency Shelter (including hotel or motel paid for with voucher)
Hospital or other residential non-psychiatric medical facility
Jail, prison
Long-term care facility or nursing home
Psychiatric hospital or other psychiatric facility
Substance abuse treatment facility or detox center
Residential project or halfway house with no homeless criteria
Hotel or motel paid for without emergency shelter voucher
Transition Housing Host Home (non-crisis)
Staying or living with a friend
Staying or living with a family member
Rental by you, with housing subsidy
Rental by you
Owned by you
Other
How long have you been staying there?
Please Select
One night or less
Two to six nights
One week or more, but less than one month
One month or more, but less than 90 days
90 days or more but less than one year
One year or longer
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Income and Benefits
What is the last grade in school that you completed?
Please Select
Less than Grade 5
Grades 5-6
Grades 7-8
Grades 9-11
Grade 12
High school diploma
GED
Some College
Associate's degree
Bachelor's degree
Graduate degree
Vocational Certification
Are you currently employed?
Please Select
Yes
No
What is your current position if employed? If not currently employed, what was your last position?
Do you have work experience in any of the following fields? (Check as many that apply)
Farming
Welding
Construction
Carpentry
Electrical Work
Auto-maintenance
Janitorial
Landscaping
General Office
Accounting/Finance
Other
Do you have ANY source of income?
Please Select
Yes
No
Select ALL income sources that apply to you
Alimony or other spousal support
Child support
Earned income
General assistance
Pension or retirement income from another job
Private disability insurance
Retirement income from social security
SSDI/SSI/TANF
Unemployment insurance
VA non-service connected disability pension
VA service connected disability compensation
Worker's compensation
I do not receive any income
Estimated monthly income (If you do not have any income enter 0
*
Do you receive any non-cash benefits?
Please Select
Yes
No
Select all sources of non-cash benefits that apply to you
Food stamps
WIC
TANF (Temporary Assistance for Needy Families)
TANF Child Care Services
TANF Transportations Services
Other TANF-Funded Services
Other Source
I do not receive any non-cash benefits
Estimated monthly amount of non-cash benefits (If you do not receive non-cash benefits, enter 0)
*
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Next
History of Housing and Homelessness
Where do you sleep most frequently?
Please Select
Shelters
Transitional Housing
Outdoors
Other
If you selected "Other" please explain:
How long has it been since you lived in stable, permanent housing?
Please Select
Currently in stable housing
Less than one year
One year or more
In the last three years, how many times have you been homeless?
Please Select
1
2
3
4
5
6
7
8
9
10
Greater than 10
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Next
Risks
In the past six months, how many times have you received health care at an emergency department/room
Please Select
0
1
2
3
4
5
6
7
8
9
10
Greater than 10
In the past six months, how many times have you taken an ambulance to the hospital?
Please Select
0
1
2
3
4
5
6
7
8
9
10
Greater than 10
In the past six months, how many times have you been hospitalized as an inpatient?
Please Select
0
1
2
3
4
5
6
7
8
9
10
Greater than 10
In the past six months, how many times have you used a crisis service, including sexual assault crisis, mental health crisis, family/intimate violence, distress centers and suicide prevention hotlines?
Please Select
0
1
2
3
4
5
6
7
8
9
10
Greater than 10
In the past six months, how many times have you talked to police because you witnessed a crime, were the victim of a crime, or the alleged perpetrator of a crime, or because the police told you that you must move along?
Please Select
0
1
2
3
4
5
6
7
8
9
10
Greater than 10
In the past six months, how many times have you stayed one or more nights in a holding cell, jail, or prison, whether that was a short-term stay like the drunk tank, a longer stay for a more serious offense, or anything in between?
Please Select
0
1
2
3
4
5
6
7
8
9
10
Greater than 10
Have you been attacked or beaten up since you've become homeless?
Please Select
Yes
No
Have you threatened to or tried to harm yourself or anyone else in the last year?
Please Select
Yes
No
Do you have any legal stuff going on right now that may result in you being locked up, having to pay fines, or that make it more difficult to rent a place to live?
Please Select
Yes
No
Does anybody force or trick you to do things you do not want to do?
Please Select
Yes
No
Do you ever do things that may be considered to be risky, like exchange sex for money, run drugs for someone, have unprotected sex with someone you don't know, share a needle, or anything like that?
Please Select
Yes
No
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Socialization and Daily Functioning
Is there any person, past landlord, business, bookie, dealer, or government group like the IRS, that thinks you owe them money?
Please Select
Yes
No
Do you get any money from the government, a pension, an inheritance, working under the table, a regular job, or anything like that?
Please Select
Yes
No
Do you have planned activities, other than just surviving, that make you feel happy and fulfilled?
Please Select
Yes
No
Are you currently able to take care of basic needs like bathing, changing clothes, using a restroom, getting food and clean water and other things like that?
Please Select
Yes
No
Is your current homelessness in any way caused by a relationship that broke down, an unhealthy or abusive relationship, or because family or friends caused you to become evicted?
Please Select
Yes
No
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Wellness
Have you ever had to leave an apartment, shelter program, or other place you were staying because of your physical health?
Please Select
Yes
No
Do you have any chronic health issues with your liver, kidneys, stomach, lungs, or heart?
Please Select
Yes
No
If there were space available in a program that specifically assists people that live with HIV or AIDS, would that be of interest to you?
Please Select
Yes
No
Do you have any physical disabilities that would limit the type of housing you could access, or would make it hard to live independently because you'd need help?
Please Select
Yes
No
When you are sick or not feeling well, do you avoid getting help?
Please Select
Yes
No
FOR FEMALE RESPONDENTS ONLY: Are you currently pregnant?
Please Select
Yes
No
Has your drinking or drug use led you to being kicked out of an apartment or program where you were staying in the past?
Please Select
Yes
No
Will drinking or drug use make it difficult for you to stay housed or afford your housing?
Please Select
Yes
No
Have you ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place you were staying, because of a mental health issue or concern?
Please Select
Yes
No
Have you ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place you were staying, because of a past head injury
Please Select
Yes
No
Have you ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place you were staying, because of a learning disability, developmental disability, or other impairment?
Please Select
Yes
No
Do you have any mental health or brain issues that would make it hard for you to live independently because you'd need help?
Please Select
Yes
No
Are there any medications that a doctor said you should be taking that, for whatever reason, you are not taking?
Please Select
Yes
No
Are there any medications like painkillers that you don't take the way the doctor prescribed or where you sell the medication?
Please Select
Yes
No
YES OR NO: Has your current period of homelessness been caused by an experience of emotional, physical, psychological, sexual, or other type of abuse, or by any other trauma you have experienced?
Please Select
Yes
No
Back
Next
Thank you!
A case manager will contact you to go over your application and guide you in your next steps to receive assistance. Please contact us with any questions you may have at services@adullamalabama.org.
Submit
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