NMD's Pre Placement Appraisal
|
|
- Milton Golden
- 8 years ago
- Views:
Transcription
1 NMD's Pre Placement Appraisal Attachment A Client's Name: Date: DOB: Birthplace: US citizen? Y/N Current Address or Placement: Social Worker or Probation Officer attending this meeting: County of Case Origination: Contact information: Client's Statement of Interest and Intent: "I am here today because... Client describes his goals and challenges: "What I really want to do is... Client describes his fears and concerns: "What stops me from moving forward is...
2 Accounts: O [ have a savings account Name of Bank:: Current Balance: $ I have a checking account Name of Bank:: Current Balance: $_ I I I have a credit card Name of Card: Current Balance: $ Current Financial Information Outstanding Debt ancl Bills: O Monthly Cell phones charges HH Monthly Car Payments [~1 Monthly Car Insurance H Other Loans Health Insurance Q Unpaid taxes D Other Income Sources: O Child Support Q Employment Income O Food Stamps O General Public Assistance O Medicaid HH No Financial Resources HH Section 8 Housing Q State Children's Health Insurance Program O Social Security G Social Security Disaioiiity Insurance (SSDI) Q Supplemental Social Security Income (SSI) G Temporary Aid-Needy Families (TANF) O Unemployment Benefits [Zl Veterans Benefits O Veterans Healthcare D Other: _^ ^^_ Work History Work history : (List all past work experiences) From Employer_ Address Position/Title to Salary per hour $ Average hours per week Supervisor Phone Duties/Skills Reason for Leaving Would they hire you back? Why or why not From Employer_ Address Position/Title to Salary per hour $ Average hours per week Supervisor Phone Duties/Skills Reason for Leaving Would they hire you back? Why or why not_
3 Information on the important people in my life (Permanent Connections) Name Address Contact phone number Name Address Contact phone number Name Address Contact phone number Legal Information Arrest Status: I I have been arrested! have never been arrested D Jailed O Juvenile Hall O Detained l~~l Restitution Please list your arrest history: Date Age Charge What Happened? Probation Officer Commitment Length Medical Information Do you have any allergies? Please describe: Please list all of the medications you are currently taking: Medication Name Frequency Doctor Diagnosis Date Started Current Doctor: Name: Address: When was your last visit?
4 Counseling: 0 I arn currently seeing a counselor. Counseling History Past Counseling: O I have seen a counselor in the past. Counselor Information: Name: Agency: Location: Date Started: 1 am still having these problernss: Counselor Information: Name: Agency: Location: Date Started: Date Ended: Critical Issues Have you ever been the victim of the following abuses? If yes, please explain briefly O Emotional Abuse Q Neglect G Physical Abuse O Sexual Abuse dl Sexual Assault Personal Belongings If you are accepted into THP+FC what would you bring with you? (Please list each item) Furniture PI Decorations
5 I I Stereo Equipment 1 1 Appliances d] Vehicles (Must have current Driver's License, registration, and insurance) D Other Additional Questions What do you know about THP+FC and how do you think it can help you? What steps have you taken to prepare yourself for THP+FC? Have you had training in independent living skills? What are your best independent living skills? What would you like to do in the future to earn money and support yourself? How do you dea! with stress? Describe what types of behaviors you have when you are stressed. Have you ever been fired from a job? Yes No If so, explain why you were fired.
6 How do you deal with authority figures? (Example: teachers, law enforcement, bosses, staff, etc.) How do you deal with peer pressure? How well do you get along with others? How do you think the THP+FC can help you to become more self-sufficient? Additional Information:
Easy Does It, Inc. Transitional Housing Application
Easy Does It Inc. of Reading and Leesport Housing Programs Easy Does It, Inc. Transitional Housing Application Welcome Thank you for applying to Easy Does It, Inc. ( EDI ) a non-profit charitable organization
More informationCentral 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 informationName Date of Birth (Last) (First) (Middle initial) Address City. State Zip County Drivers Lic/ID. Home Telephone Cell Work.
Christian Community Action 200 S. Mill Street, Lewisville, TX 75057 972-436-HELP www.ccahelps.org Please Print Name as it appears on picture ID. Today s Date Name Date of Birth (Last) (First) (Middle initial)
More informationAdmission Application
Admission Application Kids in Focus Girls in Focus Little Kids in Focus Little Kids in Focus II Kids in Focus II Instructions: When completing the application please do not leave blanks. If the requested
More informationName of victim (last, first, middle) Home telephone Work telephone. Name of claimant (last, first, middle) Home telephone Work telephone
Personal injury compensation application JD-VS-8PI Rev. 12/07 section one - Victim information Name of victim (last, first, middle) Home telephone Work telephone Address cell telephone age City State Zip
More informationSAMPLE 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 informationBilingual 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 informationApplication 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 informationTOWN OF GORHAM NEW HAMPSHIRE
TOWN OF GORHAM NEW HAMPSHIRE APPLICATION FOR PUBLIC ASSISTANCE CASE # Date of Application Referred by 1. General Information: Name Date of Birth Address Telephone Social Security number US Citizen? Marital
More information24. How does your disability keep you from working, or cause problems in your ability to maintain work? phone: phone: phone: date(s) date(s) date(s)
USOR-4 (Rev. 8/04) Utah State Office of Rehabilitation VOCATIONAL REHABILITATION APPLICATION PART I: Tell us about yourself. 1. Social Security Number (Office use only) Case #: 2. Legal Name (Last) (First)
More informationACCESS TO JUSTICE PROGRAM. (Our office will not accept phone, email, or walk-in inquiries about your application or case)
ACCESS TO JUSTICE PROGRAM (Our office will not accept phone, email, or walk-in inquiries about your application or case) Please review the following before completing application: The Center s Legal Program
More informationUNDER DEVELOPMENT CLASS TITLE: Social Work Support Technician (currently Youth Residential Worker 1)
OCCUPATIONAL GROUP: Social Services CLASS FAMILY: Social Work CLASS FAMILY DESCRIPTION: This family of positions includes those whose purpose is to provide social services to various populations, including
More informationINFORMATION ABOUT YOU
NOTE: With this type of form, to be completed by the client you would want the top portion to approximate your letterhead in case someone picked up this form for another to complete or some other reason
More informationEMPLOYMENT OPPORTUNITY
HUMAN RESOURCES / COUNTY EMPLOYMENT Location: 434 NE Evans Street Mailing Address: 535 NE 5 th Street McMinnville, Oregon 97128 (503) 434-7504 Job Line (503) 434 7553 Fax EMPLOYMENT OPPORTUNITY Occupational
More informationDomestic Violence Resource Guide for Mecklenburg County Including Information about Domestic Violence Protective Orders
Domestic Violence Resource Guide for Mecklenburg County Including Information about Domestic Violence Protective Orders Qualifications for a DV Protective Order (50B) 1. Must be a resident of Mecklenburg
More informationSUPERIOR COURT OF THE DISTRICT OF COLUMBIA CRIME VICTIMS COMPENSATION PROGRAM 515 Fifth Street, N.W., Suite 109 Washington, D.C.
SUPERIOR COURT OF THE DISTRICT OF COLUMBIA CRIME VICTIMS COMPENSATION PROGRAM 515 Fifth Street, N.W., Suite 109 Washington, D.C. 20001 APPLICATION FOR CRIME VICTIMS COMPENSATION DATE RECEIVED: CLAIM NUMBER:
More informationWe Do Business in Accordance to the Federal Fair Housing Law
PLEASE COMPLETE IN FULL Housing Authority of the City of Fort Myers Public Housing Application SOUTHWARD VILLAGE APTS. 3040 Franklin Street, Fort Myers, FL 33916 Telephone (239) 332-6635 Fax (239) 344-3273
More informationProtective Orders in Virginia A Guide for Victims
Protective Orders in Virginia A Guide for Victims Virginia Department of Criminal Justice Services www.dcjs.virginia.gov This brochure is intended to provide summary information regarding family abuse
More informationSocial Security # Date of Birth Age. Mailing Address City State Zip Code. Race Gender Height Weight Religious preference
VCU ADMISSION APPLICATION (804) 828-8822 Fax: (804) 828-9879 SERVICE REQUESTED 30-Day Evaluation 15-Day Evaluation Child s Name (please print) Nickname Social Security # Date of Birth Age Mailing CHILD
More informationResponsibilities. Arnold Schwarzenegger. Governor, State of California. Helping California Crime Victims Since 1965
Your Restitution Responsibilities a Brochure for Adult and Juvenile Offenders Arnold Schwarzenegger Governor, State of California Helping California Crime Victims Since 1965 800.777.9229 www.victimcompensation.ca.gov
More informationPRETRIAL DUI DIVERSION INFORMATION SHEET
PRETRIAL DUI DIVERSION INFORMATION SHEET If you have been charged with Driving Under the Influence of Alcohol and/or Drugs or an alcohol related charge, you may be eligible for consideration for the City
More informationVICTIM COMPENSATION APPLICATION
OFFICE OF THE ATTORNEY GENERAL Crime Prevention & Victim Services Crime Victim Compensation Division Post Office Box 220 Jackson, Mississippi 39205-0220 1-800-829-6766 or 601-359-6766 601-576-4445 (FAX)
More informationY- AmeriCorps Application
Y- AmeriCorps Application PERSONAL PROFILE NAME: LAST FIRST MIDDLE Are you a United States citizen, national, or lawful permanent resident alien? Yes No If you are a lawful permanent resident alien and
More informationFederal Programs That Can Fund Employment for Homeless People 1
Federal Programs That Can Fund Employment for Homeless People 1 Food Stamp Employment and Training Program (FSET) U.S. Department of Agriculture 100 percent Federal administration grants; 50/50 Federal
More informationName of victim (last, first, middle) Birth date Age. Address City State Zip. Gender: m Female m Male m Other
PERSONAL INJURY COMPENSATION APPLICATION JD-VS-8PI 10/12 We are here to help. If you have any questions about filling out this application or the Compensation Program, please call us toll-free at 1-888-286-7347.
More informationIOWA VETERANS TRUST FUND ASSISTANCE REQUEST
Please Submit to: IOWA DEPARTMENT OF VETERANS AFFAIRS Camp Dodge Bldg 3465, 7105 NW 70 th Avenue Johnston, Iowa 50131-1824 Phone (515) 727-3440 www.iowava.org Personal and Military Data Full Name (First)
More informationHMIS 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 informationMONTANA JUDICIAL DISTRICT COURT COUNTY
Name Address City State Zip Code Phone Number [ ] PETITIONER/[ ] RESPONDENT PRO SE MONTANA JUDICIAL DISTRICT COURT COUNTY In re the Marriage of:, Petitioner, and, Respondent. Cause No.: [ ] Petitioner
More informationPERSONNEL SERVICES Form 4120 Employment Employment Application - Certificated Staff LAQUEY R-V APPLICATION FOR A CERTIFICATED POSITION
PERSONNEL SERVICES Form 4120 Employment Employment Application - Certificated Staff LAQUEY R-V APPLICATION FOR A CERTIFICATED POSITION The School District considers applicants for all positions without
More informationMONTANA JUDICIAL DISTRICT COURT COUNTY
Name Address City State Zip Code Phone Number WIFE, PETITIONER PRO SE Name Address City State Zip Code Phone Number HUSBAND, PETITIONER PRO SE MONTANA JUDICIAL DISTRICT COURT COUNTY In re the Marriage
More informationVictim Services Program:
Victim Services Program: Mission Statement: To provide crisis intervention, emotional and judicial support and critical services referrals to aid victims and their children, and to promote community awareness
More informationCarroll College Matched Education Savings Account Application
PERSONAL INFORMATION Name: Social Sec. No. (last four digits): Gender: Female Male Date of Birth: / / Ethnicity: African American Caucasian Latino or Hispanic Asian, Pacific Islander Native American Other
More informationBUSINESS MICROLOAN APPLICATION. Quin Rivers, Inc.
BUSINESS MICROLOAN APPLICATION Quin Rivers, Inc. 12025 Courthouse Circle, New Kent, VA 23124-0208 Tel: (804) 966-8752 Fax: (804) 966-8739 Thank you for contacting Quin Rivers for a business loan. The basic
More informationFRUITA POLICE DEPARTMENT
FRUITA POLICE DEPARTMENT Personal History Form for Police Officer Applicants Personal Full Legal Last First Middle Name Sex Height Weight Hair Eyes Social Security Number Driver s License No. State Expiration
More informationName of victim (last, first, middle) Birth date Age. Address City State Zip. Gender: Female Male Other
PERSONAL INJURY COMPENSATION APPLICATION JD-VS-8PI 5/14 We are here to help. If you have any questions about filling out this application or the Victim Compensation Program, please call us toll-free at
More informationApplication for Payment Plans and Deferred Payments Personal Identification Names Case No.:
Application for Payment Plans and Deferred Payments Personal Identification s Case No.: Date of Birth Sex Social Security Number Driver's License/ Identification Number Addresses Current or temporary address
More informationFAST TRACK. Educational Assistance Program of the Community Foundation of Sarasota County ********** Application Form
FAST TRACK Educational Assistance Program of the Community Foundation of Sarasota County ********** Application Form 01/2015 HELPFUL TIPS FOR COMPLETING THE COMMUNITY FOUNDATION OF SARASOTA COUNTY FAST
More informationsubmitted with your IDA application. Incomplete applications cannot be considered.
FOR OFFICE USE ONLY Date submitted: Program Staff: Oregon IDA Application Form Please fill out this application completely to the best of your ability. Refer to the checklist, on the last page, for required
More informationAugust 2014 Report No. 14-705
John Keel, CPA State Auditor A Report on Executive Compensation at State Agencies Report No. 14-705 A Report on Executive Compensation at State Agencies Overall Conclusion The decisions of state agencies
More informationVocational Rehabilitation Handbook of Services
Vocational Rehabilitation Handbook of Services Employment Services for People with Disabilities We help people with disabilities find employment. To help Kansas citizens with disabilities meet their employment
More informationGovernment Benefits and Participation in Service Programs What government benefits do people with disabilities often receive?
Government Benefits and Participation in Service Programs What government benefits do people with disabilities often receive? Can participating in service jeopardize an individual s eligibility for government
More informationMental Health and Social Services District Questionnaire
Form Approved OMB No: 0920-0445 Expiration Date: 09/30/2012 Mental Health and Social Services District Questionnaire School Health Policies and Practices Study 2012 Attn: Tonja Kyle/Alice Roberts, Project
More informationREDUCE OR ELIMINATE YOUR STATE CHILD SUPPORT ARREARS!
XAMP FRIEND OF THE COURT Renae Topolewski ASSISTANT FRIEND OF THE COURT Edward V. Messing, Jr. ST. CLAIR COUNTY FRIEND OF THE COURT 31 st Judicial Circuit 201 McMorran Blvd., Room 1600 Port Huron, Michigan
More informationWE CAN HELP YOU! DTE ENERGY OFFERS A LOW INCOME SELF- SUFFICIENCY PLAN (LSP)
WE CAN HELP YOU! DTE ENERGY OFFERS A LOW INCOME SELF- SUFFICIENCY PLAN (LSP) This program allows you to make affordable monthly payments based on your income. The remaining portion of your bill is paid
More informationInformation on Legal Relationships and Public Benefits for Grandparents Raising Grandchildren
Information on Legal Relationships and Public Benefits for Grandparents Raising Grandchildren FROM ATLANTA LEGAL AID SOCIETY S GRANDPARENT/RELATIVE CAREGIVER PROJECT & GEORGIA SENIOR LEGAL HOTLINE Supported
More informationRelationship to Victim. Mailing Address City/State/Zip. SSN Date of Birth. Home Telephone Cell phone Other. Email address
State of Alaska Violent Crimes Compensation Board Application for Crime Victim Compensation Application for Crime Victim Compensation Section 1 Claimant A separate application must be completed for each
More informationDebt Collection Guide
Debt Collection Guide Update This Update includes new information you should know when dealing with debt collectors. 1. In New York, a debt collector cannot collect or attempt to collect on a payday loan.
More informationCharity Care Checklist
Charity Care Checklist Patient Name: (Last) (First) (MI) ACCOUNT #: _ SOCIAL SECURITY #: Completed Charity Care Application Proof of Income Income Tax Form Signed, W-2(s), 1099 Two (2) Pay Stubs most recent
More information3. You can complete this form to apply for our help. To submit this paper application you can:
Montana Legal Services Association Application for Assistance HOW TO APPLY FOR HELP: 1. You can call MLSA s HelpLine at: 1-800-666-6899 The HelpLine is answered Monday Friday from 7:30 am to 6:00 pm. Sometimes
More informationClaim Form. Before you fill out this application, please read the information below. Before you complete this application:
Claim Form Before you fill out this application, please read the information below. You may qualify to receive payment if: Before you complete this application: The victim suffered physical injury or was
More informationAPPENDIX A. Part 1 ANNOTATED CODE OF MARYLAND FAMILY LAW TITLE 5 CHILDREN
APPENDIX A Part 1 ANNOTATED CODE OF MARYLAND FAMILY LAW TITLE 5 CHILDREN Subtitle 7 Child Abuse and Neglect Resource: 5-701. Definitions. (a) In general.- Except as otherwise provided in 5-705.1 of this
More informationAPPLICATION FOR DONATED DENTAL SERVICES (DDS) PROGRAM
MICHIGAN DONATED DENTAL SERVICES (DDS) Dear Applicant: In response to your request for more information regarding how to apply for donated dental care, we are pleased to provide the following information
More informationCalifornia s Alternative Sentencing Law for Veterans and Members of the U.S. Military
California s Alternative Sentencing Law for Veterans and Members of the U.S. Military You re a veteran, or maybe you re still in the military. But now you re looking at time in county jail or state prison.
More informationRequest for Innocent Spouse Relief
Form 8857 (Rev. January 2014) Department of the Treasury Internal Revenue Service (99) Request for Innocent Spouse Relief Information about Form 8857 and its separate instructions is at www.irs.gov/form8857.
More informationVOLUNTEER APPLICATION
CASA of Los Angeles Member National Court Appointed Special Advocate Association 201 Centre Plaza Drive Suite 1100 Monterey Park, California 91754 Phone 323-859-2888 Fax 323-264-5020 www.casala.org VOLUNTEER
More informationWhat you don t know can hurt you.
What you don t know can hurt you. Why you need a defense lawyer if you are charged with a misdemeanor. A misdemeanor conviction is SERIOUS A misdemeanor is not a minor crime. If you are convicted of a
More informationApplication for Legal Assistance
Application for Legal Assistance 1. What kind of problem do you need help with? Divorce Child Custody Guardianship Bankruptcy Tax Landlord/Tenant Will / Estate Planning Other 2. Applicant Information Your
More informationBrain Injury Association of New Jersey
Brain Injury Association of New Jersey 825 Georges Road, 2nd Floor North Brunswick, NJ 08902 Phone: 732-745-0200 Helpline: 1-800-669-4323 Website: www.bianj.org E-mail: info@bianj.org SOURCES OF FUNDING
More informationYouth and the Law. Presented by The Crime Prevention Unit
Youth and the Law Presented by The Crime Prevention Unit Objectives Explaining the juvenile justice system and the differences between it and the adult system. Discussing juveniles rights and responsibilities
More informationChild Abduction Unit Request for Investigation Summary
JESUS RODRIGUEZ ASSISTANT DISTRICT ATTORNEY OFFICE OF THE DISTRICT ATTORNEY COUNTY OF SAN DIEGO BONNIE M. DUMANIS DISTRICT ATTORNEY Child Abduction Unit Request for Investigation Summary San Diego 330
More informationDomestic Violence: Can the Legal System Help Protect Me?
Domestic Violence: Can the Legal System Help Protect Me? What is domestic violence? Domestic violence is a pattern of physically and/or emotionally abusive behavior used to control another person with
More informationMONTANA FOURTH JUDICIAL DISTRICT COURT MINERAL COUNTY
Name Address City State Zip Code Phone Number FORM #17 MONTANA FOURTH JUDICIAL DISTRICT COURT MINERAL COUNTY In re the Marriage of:, Petitioner, and, Petitioner. Cause No.: Department No. [ ] Wife s [
More information*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER*****
SHAREN WILSON CRIMINAL DISTRICT ATTORNEY OF TARRANT COUNTY, TEXAS PROTECTIVE ORDER UNIT Family Law Center Phone Number 817-884-1623 200 East Weatherford Street # 3040 Fax Number 817-212-7393 Fort Worth,
More informationStatutory Rape: What You Should Know
Statutory Rape: What You Should Know 2013 Why Do You Need To Read This? Many teens are concerned about the laws regarding something commonly called statutory rape. This brochure will explain what statutory
More informationHomeownership Down Payment Assistance Program
and carry a Certified Professional Inspector (CPI) designation must complete a pre-inspection of the home. 8. Grant will be forgiven in 5 years with no monthly payments required. If borrower sells, transfers,
More informationWhat happens when your child is removed from your home
What happens when your child is removed from your home This brochure answers questions about why your child was removed from your home, and what you need to do to have your child returned. Contra Costa
More informationClient information. II. Living Status
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
More informationORANGE COUNTY GOVERNMENT invites applications for the position of: CPS Social Worker*
ORANGE COUNTY GOVERNMENT invites applications for the position of: CPS Social Worker* SALARY: $22.29 - $29.41 Hourly $46,362.00 - $61,165.00 Annually OPENING DATE: 02/29/16 CLOSING DATE: 03/14/16 11:59
More informationPosition Description Form (PDF)
Position Description Form (PDF) For Washington General Service (WGS) Positions Only INSTRUCTIONS: This form is to be completed/reviewed by the supervisor of the position when: establishing a new position;
More informationSeeking Supported Employment: What You Need to Know
Self-Determination Series Seeking Supported Employment: What You Need to Know Determine Your Destiny Seeking Supported Employment: What You Need to Know Prepared by: Judith A. Cook, Ph.D. Carol A. Petersen,
More informationFINANCIAL ASSISTANCE APPLICATION: COVER LETTER
FINANCIAL ASSISTANCE APPLICATION: COVER LETTER Thank you for choosing Children s of Alabama to provide for the healthcare needs of your child. Please find attached the forms you must complete in order
More informationLast Name: First Name: Maiden Name: Street Address or PO Box: City: County: State: Zip Code: High School Graduate
Office Use Only Returning Pathways Student Yes No Initial Served : Release Forms Initial Enrollment : Release Form Drop (if applicable): Promo Release Form Income Based: Disclosure Career Pathways Initiative
More information*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER*****
SHAREN WILSON CRIMINAL DISTRICT ATTORNEY OF TARRANT COUNTY, TEXAS PROTECTIVE ORDERS Family Law Center Phone Number 817-884-1623 200 East Weatherford Street # 3040 Fax Number 817-212-7393 Fort Worth, Texas
More informationCHILD ABUSE REPORTING PROCEDURES
CHILD ABUSE REPORTING PROCEDURES REASON FOR INVESTIGATION The Grand Jury received a citizen s complaint concerning the possible mishandling of a Suspected Child Abuse Report (SCAR) by the Nevada County
More informationChildren, Youth & Families
JUNE 2010 Children, Youth & Families Roxana Torrico, MSW Senior Practice Associate rtorrico@naswdc.org MEETING THE NEEDS OF IMMIGRANT CHILDREN AND YOUTH IN CHILD WELFARE Immigrant families comprise a large
More informationPatient Finance Services Policy
Patient Finance Services Policy CONEMAUGH HEALTH SYSTEM FINANCIAL ASSISTANCE POLICY I. PURPOSE Conemaugh Health System is a community of persons committed to being a transforming, healing presence in the
More informationOur office will not accept phone, email, or walk-in inquiries about your application or case.
Modest Means Program El Paso County Bar Association, Modest Means Program, PO Box 429, Colorado Springs, CO 80901-0429 Fax: (719)473-9216 Email: modestmeans@elpasocountybar.org Our office will not accept
More informationHealth 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 informationSTATE OF NEVADA Department of Administration Division of Human Resource Management CLASS SPECIFICATION
STATE OF NEVADA Department of Administration Division of Human Resource Management CLASS SPECIFICATION TITLE GRADE EEO-4 CODE YOUTH PAROLE COUNSELOR III 40* B 13.265 YOUTH PAROLE COUNSELOR II 39* B 13.266
More informationSUPERIOR COURT OF NEW JERSEY CRIMINAL DIVISION APPLICATION TO THE DRUG COURT PROGRAM
SUPERIOR COURT OF NEW JERSEY CRIMINAL DIVISION APPLICATION TO THE DRUG COURT PROGRAM OCEAN VICINAGE DATE OF APPLICATION: NAME: ALIAS: ADDRESS: TELEPHONE #: CITY: STATE: ZIP: HOW LONG AT THIS ADDRESS: _
More informationU.S. Bureau of Labor Statistics
U.S. Bureau of Labor Statistics Social Workers Summary Social workers help people in every stage of life cope with challenges, such as being diagnosed with depression. 2012 Median Pay Entry-Level Education
More informationOFFICE OF THE ATTOR GENERAL ELIGIBILITY REQUIREMENTS
OFFICE OF THE ATTOR YGENERAL CRIME VICTIM COMPENSATION DIVISION POST OFFICE BOX 22 JACKSON, MS 3925 22 1-8-829-6766 OR 61-359-6766 61-576-4445 (FAX) If you or a family member have been a victim of a violent
More informationEffective Date: 7/10/2015. Title: Financial Assistance Policy. Document Owner: Jonathan Binder Approver(s):Professional Advisory Group
Title: Financial Assistance Policy Document Owner: Jonathan Binder Approver(s):Professional Advisory Group Effective Date: 7/10/2015 I. Policy: It is the policy of HomeCare Maryland (HCM) to adhere to
More informationBusiness Loan Application
Business Loan Application For LDC Staff Use Application received on: by Loan Program (s): 7/2015 BUSINESS INFORMATION Business Name: (Proposed or Existing) Loan Amount: $ Business Address: City County
More informationCASE MANAGEMENT INVENTORY OF SUPPORT SERVICES For Adults
COMMONWEALTH OF PENNSYLVANIA BUREAU OF DRUG and ALCOHOL PROGRAMS Division of Treatment CASE MANAGEMENT INVENTORY OF SUPPORT SERVICES For Adults NAME : SSN: ADDRESS PHONE: (Street) ISS Interval Scores CIS
More informationName Date. Address Phone. Household Size (City) (State) (Zip) How long have you lived in Louisa County? Where did you live before? How long?
1 LOUISA COUNTY COMMUNITY SERVICES 117 S. Main St., PO Box 294 Wapello, Iowa 52653 General Assistance Application Phone 319-523-5125 Name Date Address Phone (Street) (P.O. Box) Household Size (City) (State)
More informationChild Abuse, Child Neglect. What Parents Should Know If They Are Investigated
Child Abuse, Child Neglect What Parents Should Know If They Are Investigated Written by South Carolina Appleseed Legal Justice Center with editing and assistance from the Children s Law Center and the
More informationDRUG COURT DEFERRED JUDGMENT INFORMATION SHEET
DRUG COURT DEFERRED JUDGMENT INFORMATION SHEET If you have been charged with a crime involving possession of a controlled substance and/or possession of drug paraphernalia, you may be eligible to participate
More informationWELFARE ELIGIBILITY FOR PEOPLE IN DRUG TREATMENT
WELFARE ELIGIBILITY FOR PEOPLE IN DRUG TREATMENT Most people who are in drug treatment programs should be eligible for cash assistance, medical assistance, and food stamps from DPW. But they often aren
More informationM. Caroline Cantrell & Associates, PC Attorney at Law
M. Caroline Cantrell & Associates, PC Attorney at Law 8800 SE Sunnyside Road, Suite 207N, Clackamas, OR 97015 (503) 236-9211 549 NW 2nd Avenue, Canby Oregon 97013 (503) 266-0382 Date: PENDING FORECLOSURE,
More informationSingle Mom s House Application
Single Mom s House Application The Single Mom s House is a ministry of Liberty Bible Church in Chesterton, Indiana. This is a place where you can experience growth and restoration as you move toward self
More informationGeorgia Lions Lighthouse Foundation Better vision. Better hearing. Better Georgia.
Georgia Lions Lighthouse Foundation Better vision. Better hearing. Better Georgia. Thank you for contacting the Georgia Lions Lighthouse Foundation Hearing Program for hearing aid assistance. The Lighthouse
More informationMoving On. Transition Tips for Young Adults
Moving On Shriners Hospitals for Children Intermountain Fairfax Road at Virginia Street Salt Lake City, Utah 84103 801 536 3500 http://www.shrinershq.org/hospitals/salt_lake_city/ Transition Tips for Young
More informationMUSKEGON COUNTY TREASURER TONY MOULATSIOTIS, TREASURER
MUSKEGON COUNTY TREASURER TONY MOULATSIOTIS, TREASURER 173 E APPLE AVE STE 104 MUSKEGON MI 49442 PHONE :(231 )724-6261 FAX: (231 )724-6549 COUNTY OF MUSKEGON FINANCIAL HARDSHIP EXTENSION POLICY This policy
More informationOFFICIAL REFERENDUM BALLOT TOWN OF LEBANON, MAINE JUNE 12, 2012
OFFICIAL REFERENDUM BALLOT TOWN OF LEBANON, MAINE JUNE 12, 2012 REFERENDUM 1: Shall the Town of Lebanon vote to authorize the Board of Selectmen to expend up to $70,000.00 for structural repairs, including
More informationName: Address: Email Address: Best time to contact:
Vehicle Application ALL SECTIONS (INCLUDING THE ATTACHED BUDGET FORM) MUST BE COMPLETED FOR YOUR APPLICATION TO BE REVIEWED CONTACT INFORMATION Name: Address: City: State: Zip: County/Township: Day Phone:
More informationHOME OWNER INFORMATION WORKSHEET
HOME OWNER INFORMATION WORKSHEET Homeowner (A) Homeowner (B) Homeowner (A) Street Address City State Zip Code Homeowner (B) Street Address City State Zip Code Property Address (if different) City State
More informationgovernment benefits planning: what claimants need to know
government benefits planning: what claimants need to know Government Benefits Hotline: 800-683-4872 info@settlement-alliance.com www.settlement-alliance.com My family relies on Medicaid and Supplemental
More informationForeclosure Intervention Client Counseling Session Packet
Foreclosure Intervention Client Counseling Session Packet IMPORTANT CLIENT NOTICE All Clients must complete all pages in this packet and provide all requested documents before an appointment can be scheduled.
More informationCHILD ABUSE EMERGENCY RESPONSE EFFECTIVENESS
CHILD ABUSE EMERGENCY RESPONSE EFFECTIVENESS CHILD ABUSE EMERGENCY RESPONSE EFFECTIVENESS SUMMARY The 2010-2011 Orange County Grand Jury has completed a review of the effectiveness of Emergency Response
More information