Assessment
**All adults in the same household need to fill out individual assessments.**
Do you Have Children Under 18 living with you?
*
Yes,
No
Are you FREE FROM violent or sexual charges?
*
Yes,
No
Can you Pass a Drug Screen?
*
Yes,
No
If you answered NO to any of the previous questions, YOU DO NOT QUALIFY for our program.
Person Completing Form:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number to call back:
*
Format: (000) 000-0000.
Email Address:
example@example.com
Full Name:
*
First Name
Middle
Last Name
Other last names EVER used:
*
Marital Status:
Gender:
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Race(s):
Last 4 of social:
Do you have a Photo ID?
Yes,
No
Employment Status:
Employed
Unemployed; Looking for work
Unemployed; Not looking for Work
*Do you have transportation?
*Do you have Family or friends that help you out?
Are you currently homeless?
Yes
No
Other
1. In what city, county, and state did you LAST PERMANENTLY reside?
**What county do you CURRENTLY reside?
Sebastian
Crawford
Franklin
Sequayah
Leflore
Other
2. How soon are you looking to coming here?
3. Are you working with any other agencies?
Yes,
No
4. Which Agencies?
5. Are you a domestic violence victim?
Yes,
No
*When did it occur?
When did it occur? Are you currently fleeing?
6. Do you have an open DHS/DCFS/CPS case?
Yes,
No
Other
7. Have you stayed here or at another shelter?
Yes,
No
*Where?
Why did you leave?
8. How many people, Including yourself, are in your household?
9. Is anyone in your household pregnant?
Yes,
No
If yes, when is the due date?
10. Is there more than one adult in your household?
Yes
No
*If yes, what is their name? PLEASE NOTE (they will also need to fill out an assessment)
11. Complete the following for EACH child:
Rows
Name
Age
Birthday
Gender
Grade
School/Daycare
Current on Immunizations
Birth certificate?
Social security card
How often will the child be with you?
1
2
3
4
5
6
7
8
12. Do you have a disabling physical or mental health condition?
Yes
No
* What is the condition?
13. Have you applied for disability?
Yes,
No
Denied
Approved
Still waiting for decision.
14. Have you ever struggled with or been treated for substance abuse?
Yes,
No
* When?
15. Can you pass a drug and alcohol test now including medical THC?
Yes,
No
*When was the last time you drank alcohol or used a controlled substance?
*What is your substance(s) of choice?
16. Does anyone in the family take a controlled substance?
Yes,
No
*If yes, who is prescribed and what do they take?
17. Have you ever been arrested or convicted of criminal charges? In any State?
Yes,
No
**Have your Juveniles been arrested or convicted of criminal charges? In any State?
Yes,
No
Other
If yes, what City, State & County?
What were the charges?
18. Are you currently on parole or probation?
Yes,
No
Who is your Supervising Officer?
19. Have you had a cough lasting 2 or more weeks and/or producing yellow or green sputum?
Yes,
No
20. Have you experienced drenching night sweats or rapid weight loss in the last 2 weeks?
Yes,
No
21. Have you ever tested positive for any of the following:
on a TB skin test?
HIV
Hepatitis Type A
Hepatitis Type B
Hepatitis Type C
I attest that the information above is true to the best of my knowledge.
Signature
*
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: