Hunts Haven for Veteran Intake Form

Hunts Haven for Veterans Intake Form

Full name

First NameLast Name

Age

Phone Number

Email Address

example@example.com

Current Address

Emergency Contact Name

Relationship

Phone

Gender MaleFemaleTransgender Other:

Whats your primary language

What is your relationship status?

Other

Identification & Documentation

ID Number

Expiration Date

Date

Social Security Number (Last 4 digits):

Are you currently on probation or parole?YesNo

If yes list supervising officer name and contact

Do you have any medical conditions we should be aware of?

Are you currently taking any medications?YesNo

Do you require special accommodations due to a disability?

Describe

Primary Care Provider Name

Phone

Are there any identified, past or current, domestic violence issues?YesNo

If yes, please describe, with dates of incidents.

Is applicant a Veteran, (anyone who has been on active military duty)?YesNo

Child Welfare Involvement: For Parents of minor children, including non-custodial parents, history of child

Child Welfare Involvement For Parents of minor children including noncustodial parents history of child welfare involvement including current case status

welfare involvement, including current case status:

Have you previously lived in a shared housing or group home setting?YesNo

Is this person at risk of homelessness?YesNo If yes, please describe circumstances

yes please describe circumstances

Length of homelessness this episode:

At least 1 month but less than 6 months

At least 6 months but less than 1 year

At least 1 year but less than 2 years

Within the last four 4 years how many nights months or years if any have you spent in a shelter s

Can you provide the names and dates of your shelter stay

Date

Where have you slept for the last thirty (30) days? Check all that apply.

Non-housing (Street, park, car)

Emergency shelter please name Treatment Facility Rental Housing

Psychiatric FacilitySubstance Abuse

Domestic Violence Shelter Motel/hotelFoster Care

Is applicant receiving a housing subsidy?Yes

What type of housing subsidy is the applicant receiving

Does/did applicant pay own rent?Yes

Does/did applicant pay for own utilities?

Reason for leaving last housing situation. unpaid rent

Eviction for reason other than

Conflict with friends or family

Hospitalization, including long term treatment

Other

Does applicant have a disability of a long duration?Yes

Do you have a history of any of the following: Substance use if yes, what/ frequency/ last date of use?

Mental health treatmentBehavioral issues in shared housingMental illness if yes, what

Alcohol abuse if yes, what/ frequency/ last date of use?

Drug overdose if yes, when and what?

Victim of Sexual abuse/assault

Does applicant have any current or past history of substance abuse treatment?Yes

Is applicant involved in any 12-step or other self-help recovery programs?Yes

Does applicant have a history of any psychiatric conditions?Yes

If yes please list hospitalizations for these conditions

Does applicant receive psychiatric care?Yes

No If yes, please list name, address and phone number

of all psychiatric care providers.

Do you have a caseworker or social service contact?Yes

Name

Phone

Does applicant have a history of any medical conditions?Yes

Please list hospitalizations for these medical conditions.

Date of last physical; OB/GYN, and dental appointments:

Is applicant allergic to any medications If yes, what and reaction?

Please list current medication list:

Where is the pharmacy and phone number

Describe applicant participate in any social networks, or recreational activities? Please list the name(s) of the

What is the applicants main source of income

Does applicant or anyone living with him/her have any entitlements pending?Yes

What entitlement(s) is/are pending?

a. Social Security Income (SSI) b. Social Security Disability Income (SSDI) c. General Assistance (SAGA) d. Temporary Aid to Needy Families (TANF) e. Child Support f. Alimony g. Veteran Benefits h. Employment Income i. Unemployment j. Medicare k. Medicaid 1. Food Stamps m. Other (please specify)

Include the following Date Applied Amount Receiving

Date

Please list any outstanding debts including type of debt and amount

Please list any financial obligations including the amount eg child support alimony

Is applicant currently employed, either part-time or full-time?

Is applicant currently participating in vocational or employment training programs?Yes

please identify the training program

Does applicant have any current legal issues?Yes

No If yes, please list description of charges and

Does applicant have legal representation?Yes

No If yes, please list name and address and phone

number of attorney or legal advocate.

Is applicant currently on probation?Yes

Is applicant currently on parole?Yes

Yes

If yes to either two previous above questions, please list name and contact information of probation/parole

If yes to either two previous above questions please list name and contact information of probationparole officerss

Does applicant have any prior arrests, convictions or incarceration?Yes

Does applicant have a conservator?Yes

Does the applicant have difficulty with any of the following areas of daily living? In addition, please list any strengths the tenant may have. Check all that apply. Lease Compliance Paying Rent/ UtilitiesMoney Arrangement Housekeeping

Driving / Using public transportation

Securing / Maintaining Benefits

Shopping for food and other necessities

Emergency Contact Name relationship Number

Do you require assistance with:

Are you comfortable sharing common spaces with other adults?YesNo

Do you have any allergies (food/environmental)?YesNo - List:

Employment Monthly Income Estimate: $

Are you able to pay the community fee and rent on time?YesNo

Would you like help applying for rental assistance if available?YesNo

Agreement & Signature I certify that the above information is true and accurate to the best of my knowledge.

I understand this form does not guarantee acceptance into housing.

Signature

Manager