Campus at Volusia Screening Form

1
Did you age out of foster care in Florida?* This field is required.
YESNO
2
General Information* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Date of Birth* This field is required.
Date
Year
Month
Day
5
Gender* This field is required.
Please Select
Please Select
Male
Female
6
Do you have a Florida's Driver's License / ID?* This field is required.
YESNO
7
ID / Driver's License Number* This field is required.
8
Emergency Contact Information* This field is required.
Name
Relationship
Emergency Contact Phone
9
Referral / Agency Source* This field is required.
Please Select
Please Select
Self
Independent Living
Other
10
Referral / Agency Source cont.* This field is required.
Name of person who referred you to Choices House Inc.
Relationship
Agency
Agency Phone
Agency Email
11
Highest Level of Education Completed* This field is required.
Please Select
Please Select
Elementary School
Middle School
9th Grade (Freshman)
10th Grade (Sophomore)
11th Grade (Junior)
12th Grade (Senior)
12
Last School You Attended* This field is required.
13
Do you have an Individual Education Plan?* This field is required.
YESNO
14
Do you have a high school diploma?* This field is required.
YESNO
15
Date of High School Graduation* This field is required.
Date
Day
Month
Year
16
Do you have a GED?* This field is required.
YESNO
17
Date passed GED* This field is required.
Date
Day
Month
Year
18
Are you currently enrolled in a college / trade school?* This field is required.
YESNO
19
Are you currently employed?* This field is required.
YESNO
20
Full Time or Part Time?* This field is required.
Please Select
Please Select
Full - Time
Part - Time
21
Current or Most Recent Employer* This field is required.
Company Name
Company Phone
Dates of Employment
22
What is your main source of income?* This field is required.
EFC (Extended Foster Care)
PESS Postsecondary Educational Support Services
SSI (Disability)
Other
23
Do you have a checking account?* This field is required.
YESNO
24
Do you have a savings account?* This field is required.
YESNO
25
Do you have medical insurance?* This field is required.
YESNO
26
Medical History Cont.
Primary Care Physician Name
Primary Care Physician Phone
Dentist Name
Dentist Phone
27
Please list any mental health issues past or present:* This field is required.
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Ok
Ok
28
Please list any prescribed medication that you are currently taking:* This field is required.
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Ok
Ok
29
Have you ever been hospitalized? If so, please explain:* This field is required.
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Ok
Ok
30
Substance Use - Please list current and past substance use
Age of first Use
Date of Last Use
Frequency
Cigarettes
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Row 0, Column 1
Row 0, Column 2
Alcohol
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Marijuana
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Cocaine
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Opiates
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Other
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Cigarettes
Alcohol
Marijuana
Cocaine
Opiates
Other
Age of first Use
Row 0, Column 0
Date of Last Use
Row 0, Column 1
Frequency
Row 0, Column 2
Age of first Use
Row 1, Column 0
Date of Last Use
Row 1, Column 1
Frequency
Row 1, Column 2
Age of first Use
Row 2, Column 0
Date of Last Use
Row 2, Column 1
Frequency
Row 2, Column 2
Age of first Use
Row 3, Column 0
Date of Last Use
Row 3, Column 1
Frequency
Row 3, Column 2
Age of first Use
Row 4, Column 0
Date of Last Use
Row 4, Column 1
Frequency
Row 4, Column 2
Age of first Use
Row 5, Column 0
Date of Last Use
Row 5, Column 1
Frequency
Row 5, Column 2
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31
Are you or have you ever been on probation?* This field is required.
YESNO
32
Were you a Juvenile or Adult at the time of your probation?* This field is required.
Juvenile
Adult
33
Legal History Cont.* This field is required.
Probation / Parole Officer
Phone Number
34
Please explain the nature of the incident:* This field is required.
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Ok
Ok
35
Have you ever been affiliated with a gang?* This field is required.
YESNO
36
Do you know how to cook?* This field is required.
YESNO
37
Give an example of a well-balanced meal you know how to cook:* This field is required.
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Ok
Ok
38
Do you know how to clean?* This field is required.
YESNO
39
Describe how you would clean a kitchen:* This field is required.
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Ok
Ok
40
Have you ever had a roommate?* This field is required.
YESNO
41
Was the experience positive or negative? (Explain)* This field is required.
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Ok
Ok
42
Can you make a monthly budget?* This field is required.
YESNO
43
Do you pay bills on time?* This field is required.
YESNO
44
Do you have a car?* This field is required.
YESNO
45
Do you know how to use public transportation?* This field is required.
YESNO
46
Please list your Short Term and Long Term Goals Below:* This field is required.
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Ok
Ok
47
Describe how participating in The Choices House - transitional living program will help meet the short term and long term goals you listed? * This field is required.
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Ok
Ok
48
Applicant Authorization & Signature* This field is required.I certify that the information I have provided on this application is true and correct to the best of my knowledge. hereby authorize Choices Program Organization /Campus staff to conduct a credit review, verify the information that I provided, and communicate with any and all names listed on this application. I understand that any discrepancy or omission of information may result in the rejection of this application. I understand that this is an application for THE Campus @ Volusia program, and does not constitute a rental/ lease agreement or acceptance in the program
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