Client information. II. Living Status

Transcription

1 APPLICATION Please complete this application to the best of your ability. The questions are designed to help us understand and assess your current situation. When you have completed the application call the Path-Plus office to set up an interview time and date. PATH-Plus THP-Plus of Monterey County-Provider: Peacock Acres, Inc. Toll Free PATH

2 Client information Today's Date: How did you hear about THP Plus? First Middle Last Name; Street Address: City: State: Zip; Home Phone: Cell Phone: Birth Date: Social Security Number: Identification (CA DL# or CA ID#): What is your current living situation? D Homeless Shelter HH Living independently [3] On the street n Parent/ Legal Guardian's Home Q Other Parent's home O Relative's Home Q Domestic Vioience Shelter Q Educational Institution Q Mental Hospital O Correctional/Detention Center Other Institution Do you have your Birth Certificate? D Yes No Do you have your Social Security Card? Is your driver's license valid? II. Living Status Are you currently homeless? Yes No Have you ever been homeless? Yes No Primary Language: HD English i~~l Spanish O American Sign Language D Other: ill. Demographic Information Special Needs: D Alcohol Abuse PI Developmental Disability O Domestic Violence ' (Restraining Order)OYes H]No EUDrug Abuse D HIV/AIDS G Mental illness [H Physical Disability D Other; PATH-PIUS THP-Plus of Monterey County - Provider: Peacock Acres, Inc. Toll Free PATH

3 Children: O I have Children How Many? What are the ages of your children? pregnant A female is pregnant with my baby IV. Family information Custody Order: Q 1 have a child custody order List all the members of your family (including children) Emergency Contact Information: Address: Phone: Relationship: Name Age Birth Date Relationship Where do they live? Employment Status: [3 I am currently employed Q I am currently not employed O 1 was fired O 1 was [aid-off Quit my job D have never held a job Currently looking for work V. Employment Information Current or Last Employer: Start Date:_ End Date: Hourly Pay:_ VI, Education Information Pay Stubs; D! can provide pay stubs from the last six months. Weekly Gross Income: Do you have a resume? School Status: D High School O Vocational School D College Q Not Attending School Education: Last grade completed:^ Do you have a diploma? G3 Yes HH No Do you have a GED? Q Yes D No Do you have a copy of your diploma or GED? Q Yes D No VII. Transportation Information School: Name of School: When will you graduate? Vehicle Status: 0 I own a car 1 I I do not own a car [ I use public transportation n I have a current CA Driver's license Vehicle Information: CH My car needs repair CH My car is in good running order LH My car is registered in my name n Yes ' D No insurance: CH i have car insurance Name of insurance: PATH-Plus THP-PIus of Monterey County-Provider: Peacock Acres, Inc. Toll Free Q-PATH

4 ^^P ~ - - Foster Care Status: I have been placed in: D Foster Care G Group Home O Juvenile Hall How old were vou? How many placements? VIII. I Foster Care/ Group Home Information Emancipation information: What County did you emancipate from? If you have not yet emancipated, what County will you be emancipating from? When will you emancipate? ' What is the name of your last Social Worker? Do you have a CASA? If yes, what is their name and phone number? May we contact them? IX. Legal Information Are you now or have you ever been on probation? Yes No If yes, please explain: X. Alcohol and Other Drugs Drugs 1 have tried: HIJ Alcohol QOxycontin CJ Xanax D Ecstasy D LSD D Opiates D Nicotine D Codeine O Crack' H] Mushrooms Q Hallucinogen D Vicodin D Ambien D Diet Pills D Crank O Marijuana Q Heroin D Ritalin O Inhalants D Creatine Q Cocaine 1 i Steroids DGHB D Mefhamphetamine D Other: Recovery program: G 1 am in a recovery program Proaram: How Lone? Treatment Information: CD 1 am in a residential treatment program How Lonq? Family Substance Use: Q There is a history of substance abuse in my family. Who? XL Health Insurance Information Mecii-Cal Status: D 1 have Medi-Cal What County? Do you have your card? D YesD No Health Insurance: Do you have health insurance? Company: ID#: PATH-Pius THP-Plus of Monterey County-Provider: Peacock Acres, Inc. Tod Free PATH

5 XII, Health Information if you have any medical or health issues you think we need to know about, please explain here; XIII. Previous Services I have previously participated in PATH-PIus or another California THP Plus Program: O Yes D No If yes, explain why you left the program: XIV. Character References Please list up to three adult references. Please include a reference letter from one person fisted. Name Address Phone Relationship If you need help finding telephone numbers for your references we may be able to help you. Please ask for assistance. XV. Volunteer History Please give a brief description of all community service and volunteer work performed: XVI. Essay Questions Please tell us a little about yourself and why you want to be considered for THP-Pius PATH-Plus THP-Plus of Monterey County-Provider: Peacock Acres, Inc. To//Free PATH