Central Oklahoma Community Action agency

Transcription

1 Central Oklahoma Community Action agency Norman Transitional Housing: Application/Intake Date: Are you a current or previous employee of Central Oklahoma Community Action Agency? Y or N 801 Chapel St. Norman, OK Phone: Fax: Are you a previous resident of COCAA housing? Y or N When? Name: Age: DOB: SSN: Race: Sex: M or F Contact Phone Number: Current Address or Facility: IMPORTANT: If you do not leave a contact phone number, it is your responsibility to contact COCAA regularly for the status of your application. Maiden or other name(s) you have used: Family Status: single couple separated/divorced common law Will your spouse apply to live with you? Y or N Spouse Name: Age: DOB: SSN: Race: Sex: M or F Do you have minor children? Y or N If yes, please complete the following: NAME of CHILD AGE & DOB SEX of CHILD Do you have CUSTODY of Child Child(s) SSN If your children will be living with you, are they current on immunizations? Y or N Please provide staff a copy of child s immunization record Do your children currently attend school? Y or N Where? Please list everyone who will live with you in COCAA Transitional Housing

2 If you are a single parent, please describe your relationship with your children(s) other parent What are your current living arrangements? How many times have you moved in the last 4 years? How many episodes of homelessness have you experienced in the last 4 years? Please give some reasons why you have moved: What circumstances have caused you to seek housing/case management in a Transitional Housing Program? Do you have family in the area? Y or N Are you a United States Citizen? Y or N Are you a United States Veteran? Y or N Do you currently own a vehicle? Y or N Tag #/ State: Color: Is the registration current? Y or N Year: Make/ Model: EMERGENCY CONTACT INFORMATION: (REQUIRED) Name: Phone: Address: PERSONAL REFERENCES: EDUCATION: NAME ADDRESS PHONE ( ) ( ) ( ) Are you a high school graduate? Y or N Highest level of education completed Have you attended college/ trade/vocational school? Y or N Are you currently enrolled in any kind of continuing education program? Y or N Did you complete your education/ training? Y or N

3 WORK HISTORY: Are you able to work? Y or N Are you currently employed? Y or N If not, when were you last employed? Date(s) What was your salary? $ Why did you leave your last employment? Please list any job related skills: Please complete the following regarding your work history: Dates of Employment Employer Position Held $ Salary Reason for Leaving INCOME INFORMATION: Do you currently have monthly income? Y or N Do you have income pending? Y or N Are you required to pay Child Support? Y or N If yes, amount per month $ Please complete the following and include ALL sources of income: Employment $ TANF $ Child Support $ SSI $ SSDI $ SS Income $ Other $ VA Benefits $ Unemployment $ Workers Comp $ Do you receive any of the following benefits? Food Stamps $ Medicare/Medicaid WIC Child Care Asst. $ Income received in the last 30 days $ 60 days $ 90 days $ Do you have any assets? (Savings Acct., Furniture, ect.) Y or N What assets? IDENTIFICATION: Please present staff with all types ID for entire family and a copy will be placed in your file. Drivers License (number & state) Expires State Photo ID (number & state) Expires Birth Certificate(s) Y or N Passport(s) Y or N Social Security Card(s) Y or N

4 HEALTH RELATED ISSUES: Have you ever had or been treated for a substance abuse problem? Y or N If yes, please explain: When did you last use alcohol/illegal substances: Are you currently in a recovery program? Y or N If yes, please explain Do you understand that COCAA and COCAA s Transitional Housing program has NO TOLERANCE for alcohol or drug use on or off premises while you are a resident of our housing program? Y or N Do you understand that periodic random drug/alcohol testing will occur for continued residency in our Transitional Housing program? Y or N Your signature is required as acknowledgement that you understand the above statements and agree to abide by all COCAA Transitional Housing regulations regarding alcohol/drug use. SIGN: Do you have any medical concerns that require special care such as: diabetes, epilepsy, pregnancy, high blood pressure, heart problems, ect., please explain: Have you ever been treated or hospitalized for any psychological/emotional issues? Y or N Inpatient Outpatient If yes, please list date(s), case worker, physician, treatment facility and other important information: Are you currently receiving treatment for any mental health issues? Y or N If yes, what is your current diagnosis: Are you currently taking any prescribed medications? Y or N If yes, please list all medications you are currently taking: Can you take your own medications as prescribed by your physician? Y or N Have you or any member of your immediate family ever experienced any of the following: (please check all that apply) Physical Abuse Sexual Abuse Child Abuse/Neglect Child Behavioral Problems Marital/Family Conflict Suicidal Thoughts/Attempts Substance Abuse Prostitution Runaway Please explain:

5 Did you ever receive counseling or therapy for above issues? Y or N LEGAL ISSUES: Have you ever had Public Intoxication, DUI or Drug related charges or had a Suspended Drivers License for any of the above? Y or N If yes, when? Have you ever had contact with Child Protective Services/Child Welfare? Y or N If yes, please give dates, case worker name and contact information Do you have any outstanding warrants? Y or N If yes, please explain Have you ever been convicted of a felony? Y or N If yes, please explain in detail the charges and circumstances, regarding your felony conviction, please include how resolved: Are you currently on probation or parole? Y or N If yes, you are required to provide your Probation/Parole Officer name and telephone number: Do you have other legal issues? Y or N If yes, please explain GENERAL INFORMATION: Are you considering any alternative placement at this time? Please describe your options: Are you qualified to receive housing subsidy assistance such as Section 8 or Public Housing? Yes No Don t Know How is your credit? Please explain: Are you currently working with any other social service agency? Y or N If yes, please list what agency/agencies you are involved with, and the name and contact info. of your agency worker. Are you willing and capable of working with your case manager in obtaining your goals while in COCAA s Transitional Housing Program? Please explain: What do you hope to accomplish during your residency in COCAA s Transitional Housing Program? Please explain:

6 APPLICANT IS A MEMBER OF THE FOLLOWING GROUP (check all that apply) ETHNICITY: Hispanic Not Hispanic Single Race: African-American/Black Asian Caucasian/White Native American Alaskan Native Native Hawaiian/Pacific Islander Multi Race: Native American or Alaskan Native and White Native American or Alaskan Native and Black Asian and White Asian and Black African American/Black and White Other Multiple Race All information provided is true and correct to my knowledge. Applicant Signature Date ***YOU MUST CALL OUR OFFICE AT LEAST ONCE IN 90 DAYS TO VERIFY YOU STILL NEED SHELTER OR WE WILL PURGE THE APPLICATION - ASK US FOR OUR BUSINESS CARD*** It may be necessary for COCAA staff to verify the information stated in this application. By your signature below, you grant permission to COCAA staff to contact social service agencies you may be involved with to better understand your situation and/or to release information relevant to your case. If you agree to this please indicate by signing below. Applicant Signature Date