Homeless Count and Characteristics Survey Results. West Texas Homeless Network. January 22, 2015

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Homeless Count and Characteristics Survey Results. West Texas Homeless Network. January 22, 2015"

Transcription

1 Number of surveys recorded 129 Number of adults in households 155 Number of children in households 45 Total number of people Age Age Median Gender Male Female Transgender Male to Female Transgender Female to Male Total Race American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander Black or African American White Two or More Total Hispanic or Latino Yes No Total

2 5. Physical/Mental Disability of Respondent (self-reported) Substance Abuse Disorder Chronic Physical Illness Traumatic Brain Injury HIV/AIDS Serious Mental Illness Post-Traumatic Stress Disorder Developmental Disability None of the Above Total *104 Confirmed Cases 6. Nighttime Residence of Households on 1/22/15 Emergency Shelter Transitional Shelter Permanent Supportive Housing Place Not Meant For Habitation Sharing Housing Of Others VA Domiciliary Mental Health Facility Substance Abuse Treatment Center Hospital Corrections Facility/Jail Hotel/Motel (with voucher) Hotel/Motel (with own funds) Subsidized Housing In Own Home Own Place With Imminent Eviction Substandard Housing Foster Care Or Group Home Total

3 7. Family/Household Makeup Single Individual Single Unaccompanied Minor Two Parent Family With Children Couple Without Children One Parent Family With Children Household With Only Children Other Type Of Family Total Age of Children Median Gender of Children Male Female Total Resources Needed By Children Health Care Child Care TANF WIC SNAP Total *11 Confirmed Cases

4 11. US Armed Forces Service Yes No Total Activated Into Active Duty As A Member of the National Guard or as a Reservist Yes No Total Length of Service Years Median Tour of Duty Korea Vietnam Kuwait Iraq Afghanistan Other Total Responses *10 Confirmed cases 15. Health Care or Other Benefits from VA medical Center Yes No Total

5 16. Currently Homeless (self-reported by the respondent)? Yes No Total Respondent s Situation 1st time homeless in the past 3 years episodes in the past 3 years At least 4 episodes in the past 3 years Continuously homeless for a year or more Total Length of Current Episode of Homelessness Median 4 months Range 1 day 5 years 19. Location Where Respondent Became Homeless This Time Abilene 62 Sweetwater 1 Texas 4 Out of state Homeless another time in past 12 months? Yes No Total

6 21. Reasons for Homelessness Unable to pay rent/mortgage Unemployment Divorce/separation Domestic violence Incarceration Family/personal illness Physical/mental disabilities Addiction Evicted Moved to seek work Sexual orientation Aged out of foster care Other Total *73 Confirmed Cases 22. Education Never attended st 8 th Grade Some high school High school diploma/ged Some college Technical school/job training program College graduate Master s degree or higher Total Able to work Yes No Total

7 24. Job Status Regular Full Time Regular Part Time Day Labor Temporary Job Unemployed Retired Total Length of Unemployment Months Median Needed Medical Care in the Past Year Yes No Total Received Medical Care Yes No Total Medical Care Received From ER Private Doctor VA Community Clinic MHMR Social Service Agency Other Total *54 Confirmed Cases

8 29. Needed Dental Care in the Past Year Yes No Total Received Dental Care Yes No Total Dental Care Received From ER Private Doctor VA Community Clinic MHMR Social Service Agency Other Total *11 Confirmed Cases

9 32. Needed Mental Health Care in the Past Year Yes No Total Received Mental Health Care Yes No Total Mental Health Care Received From ER Private Doctor VA Community Clinic MHMR Social Service Agency Other Total *11 Confirmed Cases

10 35. Needed Substance Abuse Treatment in the Past year Yes No Total Received Substance Abuse Treatment Yes No Total Substance Abuse Treatment Received From ER Private Doctor VA Community Clinic MHMR Social Service Agency Other Total *6 Confirmed Cases

11 38. Needed HIV/AIDS Treatment in the Past year Yes No Total Received HIV/AIDS Treatment Yes No Total HIV/AIDS Treatment Received From ER Private Doctor VA Community Clinic MHMR Social Service Agency Other Total *1 Confirmed Case 41. Services Needed Basic Needs (clothing/food) Job Training/Placement Food Stamps Transportation Assistance Case Management Veteran Benefits Total *86 Confirmed Cases

Homeless Count and Characteristics Survey Results. South Plains Homeless Consortium. January 22, 2015

Homeless Count and Characteristics Survey Results. South Plains Homeless Consortium. January 22, 2015 Number of surveys recorded 263 Number of adults in households 278 Number of children in households 73 Total number of people 351 1. Age Age Median 41.0 2. Gender Male 123 58.3 Female 88 41.7 Transgender

More information

Use block letters for text and mark appropriate boxes with an X. Complete a separate form for each household member.

Use block letters for text and mark appropriate boxes with an X. Complete a separate form for each household member. Agency Name: CLARITY HMIS: HUD-COC INTAKE FORM Use block letters for text and mark appropriate boxes with an X. Complete a separate form for each household member. PROGRAM ENTRY DATE [All Clients] - -

More information

CAMDEN COUNTY. PITC Homeless

CAMDEN COUNTY. PITC Homeless CAMDEN COUNTY On January 25, 2012 there were 662 homeless men, women and children counted in Camden County according to the U.S. Department of Housing and Urban Development (HUD) regulations. 900 PITC

More information

2016 Homeless Count Results Los Angeles County and LA Continuum of Care. Published by: Los Angeles Homeless Services Authority May 4, 2016 1

2016 Homeless Count Results Los Angeles County and LA Continuum of Care. Published by: Los Angeles Homeless Services Authority May 4, 2016 1 2016 Homeless Count Results Los Angeles County and LA Continuum of Care Published by: Los Angeles Homeless Services Authority May 4, 2016 1 Why Do We Count? The Homeless Count seeks to answer key questions

More information

Veterans Health Administration Fact Sheet

Veterans Health Administration Fact Sheet Veterans Health Administration Fact Sheet Project CHALENG - Community Homelessness Assessment, Local Education and Networking Groups Background Project CHALENG (Community Homelessness Assessment, Local

More information

State Guidelines Point in Time and Housing Inventory Count of Homeless Persons. January 2016

State Guidelines Point in Time and Housing Inventory Count of Homeless Persons. January 2016 State Guidelines Point in Time and Housing Inventory Count of Homeless Persons January 2016 Contact Information For more information concerning these Guidelines, and the Homelessness Housing and Assistance

More information

VETERANS INNOVATIONS PROGRAM APPLICATION

VETERANS INNOVATIONS PROGRAM APPLICATION VETERANS INNOVATIONS PROGRAM APPLICATION COUNTY: APPLICATION DATE: PROGRAM: Defenders Fund Individual Grant PERSONAL INFORMATION Full Name (last, first, middle) Social Security Number Phone Number Message

More information

Estimated Population Responding on Item 25,196,036 2,288,572 3,030,297 5,415,134 4,945,979 5,256,419 4,116,133 Medicare 39.3 (0.2)

Estimated Population Responding on Item 25,196,036 2,288,572 3,030,297 5,415,134 4,945,979 5,256,419 4,116,133 Medicare 39.3 (0.2) Table 3-15. Percent Distribution of Veterans by Type of Health Insurance and Age 35 Years 35-44 Years 2001 National Survey of Veterans (NSV) - March, 2003 - Page 140 45-54 Years 55-64 Years 65-74 Years

More information

SAMPLE SUPPORTIVE HOUSING INTAKE/ASSESSMENT FORM

SAMPLE SUPPORTIVE HOUSING INTAKE/ASSESSMENT FORM SAMPLE SUPPORTIVE HOUSING INTAKE/ASSESSMENT FORM (This form must be completed within 30 days of program entry) IDENTIFYING INFORMATION Date Information is Gathered: 1. Applicant Last Name: First Name:

More information

Total Males Females 34.4 36.7 (0.4) 12.7 17.5 (1.6) Didn't believe entitled or eligible 13.0 (0.3) Did not know how to apply for benefits 3.4 (0.

Total Males Females 34.4 36.7 (0.4) 12.7 17.5 (1.6) Didn't believe entitled or eligible 13.0 (0.3) Did not know how to apply for benefits 3.4 (0. 2001 National Survey of Veterans (NSV) - March, 2003 - Page 413 Table 7-10. Percent Distribution of Veterans by Reasons Veterans Don't Have VA Life Insurance and Gender Males Females Not Applicable 3,400,423

More information

Application for Vocational Rehabilitation Services

Application for Vocational Rehabilitation Services Strong Families Make a Strong Kansas Application for Vocational Rehabilitation Services Is Vocational Rehabilitation the right program for you? Some brief information about the Vocational Rehabilitation

More information

2014 Homeless Count Report

2014 Homeless Count Report Mid-Willamette Valley Community Action Agency, Community Resource Program 2014 Homeless Count Report Marion & Polk Counties A Reason to End Homelessness in Marion and Polk Counties: For many city officials,

More information

St. Louis County Project Homeless Connect. Summary of guests served on October 24, 2007

St. Louis County Project Homeless Connect. Summary of guests served on October 24, 2007 St. Louis County Project Homeless Connect Summary of guests served on October 24, 2007 J A N U A R Y 2 0 0 8 St. Louis County Project Homeless Connect Summary of guests served on October 24, 2007 January

More information

Long-Term Homeless Definitions and Eligibility Questions

Long-Term Homeless Definitions and Eligibility Questions Long-Term Homeless Definitions and Eligibility Questions Definitions Homeless (Minnesota): A household lacking a fixed, adequate night time residence (includes doubled up). Households Experiencing Long-Term

More information

Yes. Concerns expressed by: Medical Provider Primary care provider Social Service Agency Family Member Program Staff Other (Please Indicate): _

Yes. Concerns expressed by: Medical Provider Primary care provider Social Service Agency Family Member Program Staff Other (Please Indicate): _ Page 1 ~ Martin County Community Action, Inc. Head Start Program P.O. Box 806/415 E. Blvd. Suite 130 Williamston, NC 27892 (252) 789-4930 Fax: (252) 792-1838 DPlease bring proof of income, child's birth

More information

BUCKS COUNTY, PENNSYLVANIA

BUCKS COUNTY, PENNSYLVANIA BUCKS COUNTY, PENNSYLVANIA BUCKS COUNTY CONSORTIUM 2015 2019 CONSOLIDATED PLAN and 2015 ACTION PLAN Department of Housing and Community Development 1260 Almshouse Rd., Doylestown, PA 18901 Phone: 215 345

More information

BOONE COUNTY COMMUNITY SERVICES ADVISORY COMMISSION AND DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES

BOONE COUNTY COMMUNITY SERVICES ADVISORY COMMISSION AND DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES BOONE COUNTY COMMUNITY SERVICES ADVISORY COMMISSION AND DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES FY2014 Social Services Funding Process and Recommendations Presentation to Columbia City Council January

More information

2014 SAN DIEGO REGIONAL HOMELESS PROFILE

2014 SAN DIEGO REGIONAL HOMELESS PROFILE 2014 SAN DIEGO REGIONAL HOMELESS PROFILE Summary Results from the San Diego Regional 2014 Point-In-Time Count September 24, 2014 Table of Contents I. Executive Summary... 4 II. Introduction... 4 The San

More information

Counts! Bergen County s 2016 Point-In-Time Count of the Homeless. January 26, 2016

Counts! Bergen County s 2016 Point-In-Time Count of the Homeless. January 26, 2016 NJ 6 Counts! Bergen County s 6 Point-In-Time Count of the Homeless January 6, 6 Table of Contents I. Introduction... NJ Counts 6... Acknowledgements... This Report... II. Data Collection and Methodology...

More information

Public Health Management Corporation. Address: Street City Zip Code. Medical Case Manager /Housing Counselor. Email:

Public Health Management Corporation. Address: Street City Zip Code. Medical Case Manager /Housing Counselor. Email: APPLICATION COVER PAGE Agency: Address: Street City Zip Code Medical Case Manager /Housing Counselor Phone: (Print Name) Email: I attest the information and documentation submitted is accurate and verified

More information

Acknowledgements Point in Time Survey Committee Other Committee Participants Data Collection

Acknowledgements Point in Time Survey Committee Other Committee Participants Data Collection Point in Time Survey: 798 People Homeless in Maine on January 17, 2006 Acknowledgements MaineHousing wishes to acknowledge our partners and the individuals residing in shelters for their contribution to

More information

Bilingual Culinary Job Training Program. Application Form

Bilingual Culinary Job Training Program. Application Form Bilingual Culinary Job Training Program Application Form 1.- GENERAL INFORMATION: Last Name First Name Middle Name Other name (s) if any: Social Security # Date of Birth: / / Age: Gender: Female Male Current

More information

A String Theory School

A String Theory School A String Theory School www.stringtheoryschools.com West Campus Vine Street Campus East Campus 2600 South Broad Street 1600 Vine Street 2407 South Broad Street Philadelphia, PA 19145 Philadelphia, PA 19102

More information

South Dakota DOE 2013-2014 Report Card

South Dakota DOE 2013-2014 Report Card School Classification: Focus Title I Designation: Schoolwide Performance Indicators * No bar will display at the school or district level if the subgroup does not meet minimum size for reporting purposes.

More information

UWM Counseling and Consultation Services Intake Form

UWM Counseling and Consultation Services Intake Form UWM Counseling and Consultation Services Intake Form Dear Student, Date Affix Label Here (Office Use Only) Thank you for giving us the opportunity to better serve you. Please help us by taking a few minutes

More information

Monterey County Behavioral Health 2013 Satisfaction Survey Outcomes

Monterey County Behavioral Health 2013 Satisfaction Survey Outcomes SERVICE AREA - DUAL DIAGNOSIS TREATMENT DTH Co-occuring Disorder SD (BVCSOCSDV) DTH Santa Lucia (CDCSOC) Youth Surveys High Performing Indicators (75% and above) Low Performing Indicators (below 75%) Positive

More information

Lee County Central Point of Coordination Application Return Application Requested By: HIPPA Yes NO. Date of Application: / / Phone: #( )- -

Lee County Central Point of Coordination Application Return Application Requested By: HIPPA Yes NO. Date of Application: / / Phone: #( )- - Lee County Central Point of Coordination Application Return Application Requested By:_ HIPPA Yes NO Date of Application: / /Phone: #()-- Name of Applicant: Last First M.I. Current Address: City State Zip

More information

Application & Renewal Form

Application & Renewal Form Section A: I want health insurance for: (Check ( ) the category or categories that match your situation.) Myself, my spouse (or other parent of my children) and our children under age 19 who live with

More information

NOTICE OF DIRECT CERTIFICATION

NOTICE OF DIRECT CERTIFICATION East Catholic School 2001 Ardmore Blvd. Pittsburgh, PA 15221 Phone: 412/351-5403 Fax: 412/273-9114 www.eastcatholicschool.org Dear Parent/Guardian: Children need healthy meals to learn. East Catholic School

More information

Education. Date of discharge (if applicable) [Required] Total number of service years. [Required] Total years and months active duty

Education. Date of discharge (if applicable) [Required] Total number of service years. [Required] Total years and months active duty Veteran Scholarships Application Basic Information [Required] Contact Information - must be 10-15 digits long and may include only numbers, hyphens, and spaces. - name@myschool.edu First name: Middle initial:

More information

Apply for Free and Reduced Price Meals OR Prepay for Meals Online!

Apply for Free and Reduced Price Meals OR Prepay for Meals Online! Stafford County Public Schools Apply for Free and Reduced Price Meals OR Prepay for Meals Online! Dear Parent/Guardian, Stafford County Public Schools Is pleased to announce the availability of applying

More information

RENTAL APPLICATION Caldwell Housing Authority 22730 Farmway Road Caldwell, Idaho 83607 (208) 459-2232

RENTAL APPLICATION Caldwell Housing Authority 22730 Farmway Road Caldwell, Idaho 83607 (208) 459-2232 SECTION 1: APPLICANT INFORMATION RENTAL APPLICATION Accessible unit needed: Yes No (mm/dd/yyyy): Applicant Name (first, middle initial, last): Applicant (SSN): Sex: Male Female of Birth (mm/dd/yyyy): Age:

More information

Start Making the Most of Your Money!

Start Making the Most of Your Money! Start Making the Most of Your Money! Answer 23 simple questions and you will get a personal report with tips on money management and budgeting, staying healthy, and protecting your financial information.

More information

United States Military Casualty Statistics: Operation Iraqi Freedom and Operation Enduring Freedom

United States Military Casualty Statistics: Operation Iraqi Freedom and Operation Enduring Freedom : Operation Iraqi Freedom and Operation Enduring Freedom Hannah Fischer Information Research Specialist May 4, 2010 Congressional Research Service CRS Report for Congress Prepared for Members and Committees

More information

Homeless Children and Youth

Homeless Children and Youth Homeless Children and Youth Updated: October 2015 1 Although estimating the homeless population is difficult, about 1.4 million students in the U.S. were homeless at the start of the 2013-14 school year.

More information

ECEC Application Revised 01.5.15

ECEC Application Revised 01.5.15 Salt River Pima-Maricopa Indian Community Early Childhood Education Programs Mailing Address: 10, 005 E. Osborn Road Physical Address: 4815 N. Center Street Scottsdale, AZ 85256 Phone: 480-362-2200 Fax:

More information

EmployAble Pilot Study. Participant Screening and Pre-Survey

EmployAble Pilot Study. Participant Screening and Pre-Survey EmployAble Pilot Study Participant Screening and Pre-Survey EmployAble is a model Virtual Employment Orientation, Training, Resource and Support Center. It is funded by the Kessler Foundation and has been

More information

AFCARS ASSESSMENT IMPROVEMENT PLAN: Foster Care Elements State: Florida

AFCARS ASSESSMENT IMPROVEMENT PLAN: Foster Care Elements State: Florida #8 Child Race #52 1 st Foster Caretaker s Race #54 2 nd Foster Caretaker s Race (if applicable) 2 Screen: Person Management; Basic Screen/Extraction Code Screen/Code Tab 1) Modify the program code to 1)

More information

HMIS Annual Assessment Form

HMIS Annual Assessment Form Name/Identification and Contact Information: Legal First Name: Legal Last Name: Program Name: Case Manager: HMIS consent form signed? Middle Name: Suffix: Program Entry Date: / / Date of Assessment: /

More information

Trumbull Career and Technical Center 528 Educational Highway Warren, Ohio 44483 Toll Free 1-866-737-6925

Trumbull Career and Technical Center 528 Educational Highway Warren, Ohio 44483 Toll Free 1-866-737-6925 Trumbull Career and Technical Center 528 Educational Highway Warren, Ohio 44483 Toll Free 1-866-737-6925 Dear Parent/Guardian: Children need healthy meals to learn. TCTC offers healthy meals every school

More information

HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS

HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS Please use these instructions to help you fill out the application for free or reduced price school meals. You only need to submit one application per

More information

HMIS Data Standards Manual

HMIS Data Standards Manual HMIS Data Standards Manual A Guide for HMIS Users, CoCs and System Administrators Released August, 2014 U.S. Department of Housing and Urban Development Version 2.1 Contents About this Manual... 6 Key

More information

Homelessness in Greater New Orleans: A Report on Progress toward Ending Homelessness May 2012

Homelessness in Greater New Orleans: A Report on Progress toward Ending Homelessness May 2012 Homelessness in Greater New Orleans: A Report on Progress toward Ending Homelessness May 2012 Introduction The 2012 Homeless Point in Time (PIT) Count for New Orleans and Jefferson Parish took place on

More information

Neighborhood Checkup

Neighborhood Checkup Promise Neighborhoods Research Consortium (PNRC) Neighborhood Checkup Survey of Current Supports for Successful Youth Development First, we are going to ask you a few questions about your. For this survey,

More information

To be considered for our program, the following documents must be submitted on or before the deadline of March 15th:

To be considered for our program, the following documents must be submitted on or before the deadline of March 15th: 1400 Tanyard Road Sewell, NJ 08080 856-464-5203 RCGC.edu act@rcgc.edu Dear Prospective Applicant, Thank you for your interest in the Adult Center for Transition (ACT) at Rowan College at Gloucester County.

More information

Rush Center Statewide LGBT Community Survey Results Prepared for Georgia Equality and The Health initiative by the Shapiro Group

Rush Center Statewide LGBT Community Survey Results Prepared for Georgia Equality and The Health initiative by the Shapiro Group Rush Center Statewide LGBT Community Survey Results Prepared for Georgia Equality and The Health initiative by the Shapiro Group In an effort to better understand the needs of gay, lesbian, bisexual and

More information

Sacramento County and Incorporated Cities Homeless Count and Survey Report

Sacramento County and Incorporated Cities Homeless Count and Survey Report Sacramento County and Incorporated Cities Homeless Count and Survey Report June 2015 Prepared for Sacramento Steps Forward by Focus Strategies Sacramento, California Megan Kurteff Schatz, MSW, MPP Tracy

More information

BUSINESS LEADERSHIP ACADEMY APPLICATION

BUSINESS LEADERSHIP ACADEMY APPLICATION BUSINESS LEADERSHIP ACADEMY APPLICATION 500 E. 61st Street CHICAGO, IL 60637 The Sunshine Enterprises Business Leadership Academy APPLICATION DEADLINE: Must Be turned in 2 weeks prior to first day of class

More information

HARTLAND CONSOLIDATED SCHOOLS

HARTLAND CONSOLIDATED SCHOOLS HARTLAND CONSOLIDATED SCHOOLS Lisa Archey, Student Nutrition Director 10632 Hibner Rd. Telephone (810) 626 2867 Hartland, MI 48353 Fax (810) 626 2869 FREQUENTLY ASKED QUESTIONS ABOUT FREE AND REDUCED PRICE

More information

Introduction to Veteran Treatment Court

Introduction to Veteran Treatment Court Justice for Vets Veterans Treatment Court Planning Initiative Introduction to Veteran Treatment Court Developed by: Justice for Vets Justice for Vets, 10 February 2015 The following presentation may not

More information

Households Grouped By Type and Severity of Household Issues Reported

Households Grouped By Type and Severity of Household Issues Reported Appendix 2.B Details of Five Household Issue Groups Based upon Cape Cod Community Survey 2004 sample Households Grouped By Type and Severity of Household Issues Reported Table 2.B.1 provides summary descriptions

More information

EEO Employer/Vet/Disabled

EEO Employer/Vet/Disabled Job Title: Reports to: Direct Reports: Location: Staff Accountant / Payroll Finance None San Jose, CA Education Required: High School Diploma Skills Required: The ideal candidate will have at least 3 to

More information

Birth to Three, Then What?: Early Interventions role in the inclusion of children with Down syndrome

Birth to Three, Then What?: Early Interventions role in the inclusion of children with Down syndrome Birth to Three, Then What?: Early Interventions role in the inclusion of children with Down syndrome Thank you for taking the time to complete this survey. Your answers are very important to us. If you

More information

Defining & Recording Chronic Homelessness Technical Assistance Training Series March 27 th, 2015

Defining & Recording Chronic Homelessness Technical Assistance Training Series March 27 th, 2015 Defining & Recording Chronic Homelessness Technical Assistance Training Series March 27 th, 2015 INTRODUCTIONS Presenters: Lisa Mayse-Lillig, Vice President of Programming Dave Thomas, Director of Programming

More information

Survey of Registered Nurses 2008

Survey of Registered Nurses 2008 California Board of Registered Nursing Survey of Registered Nurses 2008 Conducted for the Board of Registered Nursing by School of Nursing, University of California, San Francisco and Center for the Health

More information

Central Oklahoma Community Action agency

Central Oklahoma Community Action agency 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.

More information

City of Los Angeles. 111 62 & Older 55-61 II 25-54 NI 18-24. II Under 18. Gender. 8,108 Female. 17,458 Male. ; African-American/Black

City of Los Angeles. 111 62 & Older 55-61 II 25-54 NI 18-24. II Under 18. Gender. 8,108 Female. 17,458 Male. ; African-American/Black 2015 Greater Los Angeles Homeless Count Results 25,68R total # of homeless persons City of Los Angeles Date:_id Submitted ink C Committee Oi- Council File No: 0 b olt 8-4/ c Item No.: atmeiticarwhe.444-4

More information

MDS: SUBSTANCE ABUSE/ADDICTION COUNSELORS. Demographics. Education &Training

MDS: SUBSTANCE ABUSE/ADDICTION COUNSELORS. Demographics. Education &Training MDS: SUBSTANCE ABUSE/ADDICTION COUNSELORS Demographics Year 1. Birth date 2. Sex: O Male O Female 3. Race/Ethnicity (mark one or more boxes) O American Indian or Alaska Native O Black or African American

More information

Santa Fe Recovery Center Follow Up Survey Form

Santa Fe Recovery Center Follow Up Survey Form Santa Fe Recovery Center Follow Up Survey Form Clients Name Participant ID / Chart Number Discharge Date / / Date Telephone Survey was Completed / / Month Day Year Survey Type (Check one) 3 month follow

More information

PUBLIC HEALTH - DAYTON & MONTGOMERY COUNTY APPLICATION PROCEDURES

PUBLIC HEALTH - DAYTON & MONTGOMERY COUNTY APPLICATION PROCEDURES PUBLIC HEALTH - DAYTON & MONTGOMERY COUNTY APPLICATION PROCEDURES 1. A completed Application for Employment and Consent to Procurement of Consumer Credit Report are mandatory. The Office of Human Resources

More information

Who is Homeless? NCH Fact Sheet #3 Published by the National Coalition for the Homeless, August 2007

Who is Homeless? NCH Fact Sheet #3 Published by the National Coalition for the Homeless, August 2007 National Coalition for the Homeless 2201 P. St. NW Washington, DC 20037 Phone: (202) 462-4822 Fax: (202) 462-4823 Email: info@nationalhomeless.org Website: http://www.nationalhomeless.org Who is Homeless?

More information

Family and Provider/Teacher Relationship Quality

Family and Provider/Teacher Relationship Quality R Family and Provider/Teacher Relationship Quality Provider/Teacher Measure: Short Form Provider/Teacher Measure: Short Form This measure asks about you and your early education and child care program.

More information

Children's Bureau Child and Family Services Reviews Consultant Profile Form

Children's Bureau Child and Family Services Reviews Consultant Profile Form Children's Bureau Child and Family Services Reviews Consultant Profile Form Revised April 2008 (Please Type or Print Legibly) Identifying Information First Name Middle Name/Initial Last Name Home Address

More information

Accelerated Teacher Certification Program APPLICATION

Accelerated Teacher Certification Program APPLICATION HCC STUDENT ID (Emplid): TEA ID: Please check the certificate area applying for: Bilingual Education Supplemental-Spanish (t a standalone certificate) Bilingual Generalist-Spanish (EC-6) English as a Second

More information

Boston Area Health Education Center

Boston Area Health Education Center Boston Area Health Education Center Youth to Health Careers Program Application Checklist Due March 12th, 2014 Full Name: School: Best Phone to Contact You: Grade: The Youth to Health Careers (Y 2 HC)

More information

COMMISSION ON ACCREDITATION 2011 ANNUAL REPORT ONLINE SUMMARY DATA: INTERNSHIP PROGRAMS

COMMISSION ON ACCREDITATION 2011 ANNUAL REPORT ONLINE SUMMARY DATA: INTERNSHIP PROGRAMS COMMISSION ON ACCREDITATION 2011 ANNUAL REPORT ONLINE SUMMARY DATA: INTERNSHIP PROGRAMS INTRODUCTION The Annual Report was created in 1998 to provide the American Psychological Association s Commission

More information

PRISM SECTION 1 OVERVIEW. Number of times divorced. Number of times widowed

PRISM SECTION 1 OVERVIEW. Number of times divorced. Number of times widowed START TIME : PRISM SECTION 1 OVERVIEW Statement A.1: I would like to begin by asking you some questions about your background. 1. -----------------------------------------------> Sex 1 MALE 2 FEMALE 2.

More information

Homeless Management Information System (HMIS) Indiana Housing & Community Development Authority

Homeless Management Information System (HMIS) Indiana Housing & Community Development Authority Homeless Management Information System (HMIS) Indiana Housing & Community Development Authority 3.2.2012 Homeless Management Information System (HMIS) New User Training A Homeless Management Information

More information

Mifflinburg Bank and Trust Company Application for Employment

Mifflinburg Bank and Trust Company Application for Employment Mifflinburg Bank and Trust Company Application for Employment Date Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to

More information

CAHPS Survey for ACOs Participating in Medicare Initiatives 2014 Medicare Provider Satisfaction Survey

CAHPS Survey for ACOs Participating in Medicare Initiatives 2014 Medicare Provider Satisfaction Survey CAHPS Survey for ACOs Participating in Medicare Initiatives 2014 Medicare Provider Satisfaction Survey Survey Instructions This survey asks about you and the health care you received in the last six months.

More information

Lone Tree Community School District Homeless Plan

Lone Tree Community School District Homeless Plan Lone Tree Community School District Homeless Plan Homeless Students: Definitions, Rights and Identification July, 2013 Identified Lone Tree Homeless Liaison: Mrs. Shelby Bryce, PK-12 Guidance Counselor

More information

Health Coverage & Help Paying Costs Application for One Person

Health Coverage & Help Paying Costs Application for One Person THINGS TO KNOW Health Coverage & Help Paying Costs Application for One Person Use this application to see what insurance choices you qualify for Free or low-cost insurance from Medicaid or the Kentucky

More information

L E T T E R T O H O U S E H O L D

L E T T E R T O H O U S E H O L D Free and Reduced Price School Meals Letter to Households Page 1 of 1 L E T T E R T O H O U S E H O L D Dear Parent/Guardian: School Year 2014 2015 * * * * * * * * * * * * * * * NEW THIS SCHOOL YEAR!!!

More information

Application for Employment Related Day Care (ERDC) Program

Application for Employment Related Day Care (ERDC) Program Application for Employment Related Day Care (ERDC) Program Please read these instructions before filling out this application. Answer all questions. Do not write in the shaded areas. To contact our office

More information

https://unc.qualtrics.com/wrqualtricscontrolpanel/ajax.php?a...

https://unc.qualtrics.com/wrqualtricscontrolpanel/ajax.php?a... Default Question Block The RWJF Board of Trustees is interested and engaged in the success of our scholars and alumni. The RWJF Human Capital team would like to be able to speak about our scholars and

More information

South Dakota DOE 2014-2015 Report Card

South Dakota DOE 2014-2015 Report Card Performance Indicators School Performance Index District Classification: - Exemplary Schools 1 / 24 Schools 4.17% Status Schools 1 / 24 Schools 4.17% Progressing Schools 19 / 24 Schools * No bar will display

More information

MAYOR S HOUSING THE HOMELESS TASK FORCE REPORT

MAYOR S HOUSING THE HOMELESS TASK FORCE REPORT 1 As the Task Force engages in planning strategies to end homelessness in Denton, we will need as much information about the organizations that provide, are considering providing, or talking about providing

More information

Boston Area Health Education Center

Boston Area Health Education Center Boston Area Health Education Center Youth to Health Careers Program Full Name: School: Application Checklist Due March 16th, 2016 Best Phone to Contact You: Please Circle: Home Cell Grade: The Youth to

More information

ServicePoint Supportive Service Workflow for CoC SSO Projects

ServicePoint Supportive Service Workflow for CoC SSO Projects ServicePoint Supportive Service Workflow for CoC SSO Projects 8/27/2015 10/20/2015 Update 1 Overview Supportive Service projects (SSOs) are an important piece of the process of ending homelessness in our

More information

CLIENT INTAKE REPORT. DEMOGRAPHIC TAB: Name: / / Gender: [ ] Male [ ] Female [ ] Transgender ([ ] Male to female [ ] Female to male) [ ] Unknown

CLIENT INTAKE REPORT. DEMOGRAPHIC TAB: Name: / / Gender: [ ] Male [ ] Female [ ] Transgender ([ ] Male to female [ ] Female to male) [ ] Unknown Part B URN # Client Part C # CLIENT INTAKE REPORT Date: DEMOGRAPHIC TAB: Name: / / (Last) (First) (MI) Preferred name you want to be called: Gender: [ ] Male [ ] Female [ ] Transgender ([ ] Male to female

More information

9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof.

9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof. Dear Parent/Guardian: Children need healthy meals to learn. Your child s school offers healthy meals every school day. Your childr en may qualify for free meals or for reduced price meals. 1. DO I NEED

More information

Application for Free Home Repairs

Application for Free Home Repairs Application for Free Home Repairs Name of Homeowner: Date of Birth: Gender Male Female Is this a female headed household? Is this a grandparent headed household? Street Address: City: County: Zip Marital

More information

MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT Nutrition Services 777 Garfield Avenue Milford, OH 45150 (513) 831-5030

MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT Nutrition Services 777 Garfield Avenue Milford, OH 45150 (513) 831-5030 MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT Nutrition Services 777 Garfield Avenue Milford, OH 45150 (513) 831-5030 **NOW AVAILABLE** ONLINE FREE AND REDUCED APPLICATIONS FOR MILFORD EXEMPTED VILLAGE SCHOOLS

More information

Employment Application An Equal Opportunity Employer

Employment Application An Equal Opportunity Employer Employment Application An Equal Opportunity Employer PO Box 520 76 East Market Street Xenia, Ohio 45385 937-352-4000 The Greene County Public Library considers applications for all positions without regard

More information

ATTORNEY APPLICATION FOR EMPLOYMENT DIVISION OF LAW DEPARTMENT OF LAW AND PUBLIC SAFETY STATE OF NEW JERSEY

ATTORNEY APPLICATION FOR EMPLOYMENT DIVISION OF LAW DEPARTMENT OF LAW AND PUBLIC SAFETY STATE OF NEW JERSEY ATTORNEY APPLICATION FOR EMPLOYMENT DIVISION OF LAW DEPARTMENT OF LAW AND PUBLIC SAFETY STATE OF NEW JERSEY The Division of Law provides legal counsel and representation to agencies of State government

More information

Transportation Construction Apprenticeship Readiness Training T.C.A.R.T. Cell Phone Date of Birth (mm/dd/yyyy) Gender: Male

Transportation Construction Apprenticeship Readiness Training T.C.A.R.T. Cell Phone Date of Birth (mm/dd/yyyy) Gender: Male PROGRAM APPLICATION Host CBO: Applicant # Last Name Address Home Phone SS# Email First Name City/State/Zip Cell Phone Date of Birth (mm/dd/yyyy) Middle Initial I have the legal right to work in the US.

More information

SOUTHEASTERN TECHNICAL INSTITUTE

SOUTHEASTERN TECHNICAL INSTITUTE SOUTHEASTERN TECHNICAL INSTITUTE DENTAL ASSISTING MEDICAL ASSISTING APPLICATION FOR ACADEMIC YEAR 201 6-2017 250 Foundry Street South Easton, MA 02375 Phone: 508.238.1860 Website: www.stitech.org Southeastern

More information

APPIC APPLICATION Summary of Practicum Experiences

APPIC APPLICATION Summary of Practicum Experiences APPIC APPLICATION Summary of Practicum Experiences 1. Intervention Experience How much experience do you have with different types of psychological interventions? NOTE: Remember that hours accrued while

More information

Executive MBA Program. Application for Admission

Executive MBA Program. Application for Admission Executive MBA Program Application for Admission Application Instructions ADMISSION To be considered for admission to the E. Philip Saunders College of Business Executive MBA Program, a candidate must:

More information

DANVILLE-PITTSYLVANIA COMMUNITY SERVICES 245 HAIRSTON STREET DANVILLE, VIRGINIA 24540 434-799-0456

DANVILLE-PITTSYLVANIA COMMUNITY SERVICES 245 HAIRSTON STREET DANVILLE, VIRGINIA 24540 434-799-0456 APPLICATION FOR EMPLOYMENT DANVILLE-PITTSYLVANIA COMMUNITY SERVICES 245 HAIRSTON STREET DANVILLE, VIRGINIA 24540 434-799-0456 INSTRUCTIONS: PLEASE READ CAREFULLY BEFORE COMPLETING THIS APPLICATION 1. The

More information

Veterans Trauma Courts. Hon. Ronald Crowder District Court Judge 4 th Judicial District of Colorado

Veterans Trauma Courts. Hon. Ronald Crowder District Court Judge 4 th Judicial District of Colorado Veterans Trauma Courts Hon. Ronald Crowder District Court Judge 4 th Judicial District of Colorado US Veterans US Population: 308 million Current Active and Reserve: 2.4 million.75% of US Population Total

More information

Selected Socio-Economic Data. Baker County, Florida

Selected Socio-Economic Data. Baker County, Florida Selected Socio-Economic Data African American and White, Not Hispanic www.fairvote2020.org www.fairdata2000.com 5-Feb-12 C03002. HISPANIC OR LATINO ORIGIN BY RACE - Universe: TOTAL POPULATION Population

More information

Changes in the HUD Definition of Homeless

Changes in the HUD Definition of Homeless Changes in the HUD Definition of Homeless On January 4, 2012, final regulations went into effect to implement changes to the U.S. Department of Housing and Urban Development s (HUD s) definition of homelessness

More information

Application for Admission and Scholarships Application Form

Application for Admission and Scholarships Application Form Application for Admission and Scholarships Application Form 2015-2016 Academic Year www.ohio.edu/admissions Undergraduate Admissions, Chubb Hall 120, 1 Ohio University, Athens OH 45701-2979 E-mail: admissions@ohio.edu

More information

The Math TLC Master s in Mathematics for Secondary Teachers Program

The Math TLC Master s in Mathematics for Secondary Teachers Program Math TLC Master s Application Form Page 1 The Math TLC Master s in Mathematics for Secondary Teachers Program Electronic Application Form Instructions Save your completed application a filename of the

More information

Technical Report # 15-034. Submitted by: Danna Moore, Ph.D. Arina Gertseva, Ph.D.

Technical Report # 15-034. Submitted by: Danna Moore, Ph.D. Arina Gertseva, Ph.D. CIVIL LEGAL PROBLEMS EXPERIENCED BY VICTIMS OF DOMESTIC VIOLENCE AND SEXUAL ASSAULT IN WASHINGTON STATE Findings from 2014 Civil Legal Needs Study Update Technical Report # 15-034 Submitted by: Danna Moore,

More information

Background Information

Background Information Background Information Occupation Expert for: The goal of this project is to get accurate, up-to-date information on the occupation of from a diverse

More information

INSTRUCTIONS FOR EMPLOYMENT APPLICATIONS

INSTRUCTIONS FOR EMPLOYMENT APPLICATIONS INSTRUCTIONS FOR EMPLOYMENT APPLICATIONS In order to comply with Federal and State Government requirements, a complete file on all employees is required. The employee file must consist of a completed Employment

More information

Application. For Veterans Care Health Insurance. Veterans Care covers veterans who need health insurance. Other Important Information

Application. For Veterans Care Health Insurance. Veterans Care covers veterans who need health insurance. Other Important Information Application For Veterans Care Health Insurance There are thousands of veterans in Illinois who are living without health insurance because they can t afford it. The citizens of Illinois feel a sense of

More information

CITY OF SOUTH SALT LAKE APPLICATION FOR EMPLOYMENT

CITY OF SOUTH SALT LAKE APPLICATION FOR EMPLOYMENT CITY OF SOUTH SALT LAKE APPLICATION FOR EMPLOYMENT Position applying for: Date: PERSONAL INFORMATION Name: First Middle Last Address: Number/Street City State Zip Telephone # Home: Cell: E-mail address:

More information