Tornado Group Program Application & Intake Form

1
Who is completing application/ Is this a referral?* This field is required.
Self
Case Manager
Parole / Probation
Hospital (Medical)
Hospital (Psychiatric)
Recently Released from Prison
Military / Veteran Referral
Shelter
Other
2
Referring Information* This field is required.Person completing referral
Referring Agency
Contact Name:
Title
Referring Agency Phone
Referring Agency Email
Referring Agency Address
3
I understand the program participant must be able to live independently and no clinical care or medical care will be received. Participant must be able to complete basic hygiene, cook and clean living area and ambulate on their own. I understand participant must be able to take medication independently.* This field is required.
YESNO
4
Does applicant have a mental health diagnosis* This field is required.(This will NOT disqualify applicant from housing.but helps with placement)
YESNO
5
Allergies (food, medication, environmental):
Huge
Large
Normal
Small
Ok
Ok
6
Applicant Reason for seeking housing* This field is required.Why do you want to live here
Huge
Large
Normal
Small
Ok
Ok
7
Applicant Full Legal Name* This field is required.Full Legal Name Required
Mr.
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Suffix
8
Applicant Preferred Name OptionalAdd preferred names and AKA
Name
Other Alias
9
Applicant Date of Birth* This field is required.
Date
Month
Day
Year
10
Applicant Contact Phone Numbers* This field is required.
Primary Phone Number
Alternate phone number
Alternate Contact Name (First and Last)
11
Applicant EmailEnter primary email address
example@example.com
Confirm Email
12
Applicant Born Gender* This field is required.(for placement purposes only)
Male
Female
Non-binary
Prefer not to say
13
Applicant Gender Identity (optional)Placement or safety considerations related to gender identity
14
Are there any placement or safety considerations we should be aware of?* This field is required.
Yes
No
Other
15
Applicant Current living situation* This field is required.Where have you been sleeping in last 30 days. Select all that apply
Hospital (medical reason)
Hospital (Mental Health related reason)
Homeless
Prison release
Couch Surfing
Own Home
Hotel
Car
Shelter stay
Living with relatives
Living with friends
Evicted
Other
16
Applicant Last 3 previous addresses* This field is required.Address 1
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
17
Applicant Last 3 previous addresses* This field is required.Address 2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
18
Applicant Last 3 previous addressesAddress 3
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
19
Prior housing instability* This field is required.Have you been evicted or asked to leave a living situation ( Non Court or Court situation)? This will not disqualify you from being accepted into program
YES, I haveNO, No one has EVER asked me to leave a living situation
20
Please explain brieflyWhy were you asked to leave living situation
Huge
Large
Normal
Small
Ok
Ok
21
Applicant INCOME & EMPLOYMENT* This field is required.Select all that apply(Include employment, SSI, SSDI, VA, retirement, unemployment)
Employment
SSI
SSDI
VA
Retirement
Unemployment
No Income
Other
22
EmployerList Employer and contact address and phone number
Huge
Large
Normal
Small
Ok
Ok
23
Total monthly income* This field is required.
No income
Under $500
$500–$1,000
$1,000–$2,000
Over $2,000
24
How will applicant program fees be paid?* This field is required.Who will pay reoccurring monthly fee for participant room?
Self-Pay
Agency Voucher
Sponsor
Relative
Other
25
You selected you will have a sponsor* This field is required.Include Sponsor name, relationship, address and phone number
Huge
Large
Normal
Small
Ok
Ok
26
You selected the monthly participation fee will be paid by Voucher* This field is required.Enter voucher details. Agency Name Contact Name and address and phone number of agency
Huge
Large
Normal
Small
Ok
Ok
27
List who will pay participant program month fee?* This field is required.Include name, address and phone number
Huge
Large
Normal
Small
Ok
Ok
28
Mobility, Medical Equipment, or Assistive Devices Used* This field is required.
Wheelchair
Power Chair
Shower Chair
None
CPAP
Oxygen
Ramp Needed
Other
29
Any special accommodations needed to safely participate in housing?* This field is required.
Yes
No
Other
30
Are you prescribed medications or receiving ongoing treatment?* This field is required.
Yes
No
Short Term
Long Term
Other
31
Provider InformationThis information is requested for emergency planning and referral coordination only
Provider office phone number
Primary Provider Name or office/ clinic name
32
Psychiatric Provider InformationThis information is requested for emergency planning and referral coordination only. (This will NOT disqualify applicant from housing.but helps with placement)
Provider office phone number
Provider Name or office/ clinic name
33
Therapist / Counselor InformationThis information is requested for emergency planning and referral coordination only. (This will NOT disqualify applicant from housing.but helps with placement)
Provider office phone number
Provider Name or office/ clinic name
34
Does the program applicant have a diagnosed mental health condition they wish to disclose for placement or safety planning purposes only?* This field is required.This information is requested for emergency planning and referral coordination only. (This will NOT disqualify applicant from housing.but helps with placement)
YESNO
35
What services are you receiving?This information is requested for emergency planning and referral coordination only. (This will NOT disqualify applicant from housing.but helps with placement)
PCP
Therapist
Psychiatric Provider
36
What services do you have or would like to request for Applicant* This field is required.This information is requested for emergency planning and referral coordination only. (This will NOT disqualify applicant from housing.but helps with placement)
PCP
Therapist
Psychiatric Provider
Medical Equipment
Other
37
Is Applicant Prescribed a long-acting injectable?Do you receive an injection medication? This information is requested for emergency planning and referral coordination only. (This will NOT disqualify applicant from housing.but helps with placement)
YESNO
38
Information about your injectionThis information is requested for emergency planning and referral coordination only. (This will NOT disqualify applicant from housing.but helps with placement)
Please Select
Please Select
Weekly
Every 2 weeks
Every 3 weeks
Monthly
Every 6 weeks
Every 2 months
Every 6 months
Every year
Frequency
Enter last Injection date
Location/ Facility of last Injection
Next Due Date
Please Select
Please Select
Yes
No
Next Injection appointment scheduled
39
Have applicant experienced domestic violence, or had restraining/protective orders in the past?* This field is required.This information is requested for emergency planning and referral coordination only. (This will NOT disqualify applicant from housing.but helps with placement)
YESNO
40
Has applicant Ever convicted of a crime?Misdemeanor or felony (This will NOT disqualify applicant from housing.but helps with placement)
YESNO
41
Please explain
Huge
Large
Normal
Small
Ok
Ok
42
Are there any legal restrictions or requirements that may impact shared housing placement? This information is requested for emergency planning and referral coordination only. (This will NOT disqualify applicant from housing.but helps with placement)
Huge
Large
Normal
Small
Ok
Ok
43
Do you currently have an active restraining or protective order involving another person?* This field is required. (This will NOT disqualify applicant from housing.but helps with placement)
YESNO
44
Are there any safety considerations we should be aware of?* This field is required.If no write N/A
Huge
Large
Normal
Small
Ok
Ok
45
Emergency ContactsEnter your emergency contact number
Contact #1 Phone Number
Contact #1 Name
Contact #2 Phone Number
Contact #2 Name
Contact #3 Phone Number
Contact # 3 Name
Contact #4 Phone Number
Contact # 4 Name
46
Select what documents does applicant have?* This field is required.Select all that apply
State ID
SS card
Birth certificate
Bus card
VA Identification
Health INsurance Card/ Medical Card
Passport
47
Does applicant need help obtaining any ot the following documents* This field is required.Select all that apply
State ID
SS card
Birth certificate
Bus card
VA Identification
Health INsurance Card/ Medical Card
Passport
None
Other
48
PROGRAM EXPECTATIONS.
I understand this is program-based housing, not a lease
I understand participation may be terminated for violations or safety concerns
I understand the program is drug-free and alcohol-free
I agree to follow all house rules and expectations
I agree to cooperate with emergency services if needed
I consent to relocation within a Tornado Group home if necessary for safety or program needs
I consent to a current photo being taken for my file for safety and identification purposes
No weapons are permitted
No overnight guests are allowed
Smoking/vaping is permitted only in designated outdoor areas
Chores are assigned on a rotating basis
Participation in house meetings, groups, and workshops is expected
Serious violations may result in immediate discharge
I understand I will be giving a participant packet at move-in that includes all program expectations and requirements and FAQ
I understand Tornado Group has a discharge process for rule violations or safety concerns
I understand I may submit a grievance or complaint according to program procedures
Before final approval into the program, I understand I will receive a full list of program rules, and I agree to follow them
I understand monthly program fees are required to maintain participation
I understand if the monthly program fee is not paid, I will be removed from the program and must leave the home
I understand my personal belongings will be held for up to 7 days after discharge before being discarded
I understand I must notify Tornado Group if I will be away from the home more than 24 hours or overnight
I understand I must notify Tornado Group if I am arrested, detained, or incarcerated
49
HOSPITAL DISCHARGESend following paperwork with application.
Discharge paperwork
Current medication list
Psychiatric evaluation (if psych discharge)
Follow-up appointment information
50
FEES ACKNOWLEDGMENT
Failure to maintain program fees may result in discharge according to program procedures.
I understand monthly program fees are required to maintain participation
I understand a non-refundable community/program fee will be charged prior to or at move-in
I understand the community fee is not rent, not a security deposit, and is non-refundable. It allows Tornado Group to continue operating and serving participants consistently.
I understand The community/program fee helps Tornado Group maintain a safe, stable, and fully furnished housing environment.
51
Program Acknowledgment
I understand this is program-based housing, not a lease
I understand the program is drug-free and alcohol-free
I agree to follow all house rules and expectations
No weapons are permitted
No overnight guests are allowed
Smoking/vaping is permitted only in designated outdoor areas
Chores are assigned on a rotating basis
Participation in house meetings, groups, and workshops is expected
Serious violations may result in immediate discharge
I understand Tornado Group has a discharge process for rule violations or safety concerns
Before final approval into the program, I understand I will receive a full list of program rules, and I agree to follow them
I understand monthly program fees are required to maintain participation if the participant monthly program fee is not paid, participant will be removed from the program and must leave the home
I understand there will be a curfew for program participants
Other
52
I consent to be contacted by Tornado Group regarding this inquiry.
Should be Empty: