Application for Community Living
Branch15 is a Faith-Based Organization.
● Applications will not be accepted more than 45 days from the date when residency is needed.
● All Clients will be required to find gainful employment within 30 days of admittance.
● Applicants must fill out the entire form to be considered for the program.
*Required fields are marked with an asterisk.
*Applying for: Checkboxes Checkboxes Checkboxes Checkboxes
*Today’s Date: Date *Date residency is needed: Date
*Last Name: Client last name *First Name: Client first name
*DOB: Client birthdate
Who referred you to Branch15: Text field
Military ID # if applicable: Text field Military Dates of Service: Text field Location Served: Text field
*Describe Your Current Living Location: Text field
Checkboxes
Checkboxes Doc #: Text field
Checkboxes
Other: Text field
Case Manager Name: Text field
Address:
Client Address Client City Client StateClient Zip
*Phone: Client phone *Email Address: Client email
Emergency Contact:
Name: Text field Phone: Text field Email: Text field Relationship: Dropdown
Consent to contact Emergency Contact: Checkboxes Checkboxes
DOCUMENTATION
Do you have your: *Social Security Card Radio buttons *Birth Certificate Radio buttons
TRANSPORTATION
Is your license: Checkboxes Checkboxes Checkboxes
*Do you have a car: Radio buttons
*Is your insurance current: Radio buttons Insurance Company: Text field
Application for Community Living
EDUCATION
*Grade in school completed: Text field
*Do you have a Checkboxes
Describe any job training, certificates, or education you have completed: Paragraph
CURRENT EMPLOYMENT
*Are you currently employed: Radio buttons Location of employment: Text field
Supervisor name: Text field Phone number: Text field
LEGAL INFORMATION
*Have you ever been convicted of a crime (felony/misdemeanor): Checkboxes Are you a registered sex offender: Radio buttons
Are you on probation: Radio buttons Are you on parole: Radio buttons
*Are you in any legal trouble (outstanding tickets, hot checks, court fines): Radio buttons
If yes, explain: Text field
How much do you owe in legal fines: Text field Are you making payments: Radio buttons
HEALTH INFORMATION
*Do you have food allergies: (If yes, please list all) Client allergies
*Do you have a mental health diagnosis: Checkboxes
If yes, please provide details: Client diagnosis
*Have you ever been abused: Checkboxes
Are you currently in counseling: Radio buttons
*Medications:
Medication
Application for Community Living
*Have you been through treatment for addiction: Radio buttons
If yes, where: TreatmentCenterHistory
Did you complete the program: Checkboxes
If not, why: Paragraph
*Is there a possibility you could be pregnant: Radio buttons
*Do you (smoke) Radio buttons or (vape): Radio buttons
*Are you currently receiving disability benefits: Radio buttons
*Will you be applying for disability benefits in the next 12 months: Radio buttons
*Do you have a medical or emotional issue that would prevent you from working a minimum of 35 hours per week: Radio buttons
If yes, what is the reason: Paragraph
FINANCIAL INFORMATION
*Do you have medical insurance: Radio buttons
*Do you receive food stamps: Radio buttons
*Do you agree to pay the monthly program fee of $500: Radio buttons
*Could you pay Program Fees on the 1st of the next month: Radio buttons
PERSONAL INFORMATION
Do you currently attend church: Radio buttons
If so, where: Text field
*Do you have children: Radio buttons With you: Checkboxes In DHS Custody: Checkboxes Living with family: Checkboxes
*Are you in the process of re-unification: Radio buttons
*If so, please explain the situation (number of children, age, gender, who they live with, DHS involvement, guardianship placement, etc):Paragraph
*List three (3) character references. You may only use one family member and one friend. Others would include coworkers, landlords, sponsors, mentors, ministerial staff, etc.
Name Text field Relationship Text field Phone Number Text field
Name Text field Relationship Text field Phone Number Text field
Name Text field Relationship Text field Phone Number Text field
Application for Community Living
Branch15
A Plan to Change Worksheet
(Please answer each section)
*I need to make a change and the reasons are:
Paragraph
*The following goals will help me make these changes:
Paragraph
Actions I can take to help me with my goals are:
Specific Action:Paragraph
When: Paragraph
*People who are interested in helping me achieve my goals are:
Person:Paragraph
Possible ways to help: Paragraph
*Difficulties that may obstruct my goals and how I can manage them are:
Obstacle to change: Paragraph
Possible ways to help: Paragraph
Ways to recognize my goals are working are:
Paragraph
Application for Community Living
Branch 15 assists clients with:
o Integrating Faith into daily living.
o Necessary transportation to meet the Program requirements.
o Organizational skills to successfully re-enter independent living.
o Creating and maintaining an Individual Service Plan.
o Budgeting skills
o Job searching
o Healthy conflict resolution
o Access to proper medical care
o Access to counseling services
Client and House Guidelines
o Clients work with their Program Manager and set goals for their time at Branch15; Individual Care is approximately 18 months and GenHope is approximately 26 months.
o Clients agree to work within the boundaries of the policies and procedures covered in orientation.
o Branch15 has a curfew.
o Dating policies are in place for building healthy romantic relationships.
o Clients have a chore list in their home.
o No violence or threat of violence is acceptable.
o Random UA’s are performed; positive clients are dismissed.
o Communication is necessary for healthy living in the group home.
o Attendance requirements are: church weekly, recovery weekly, Program Night weekly.
o Personal appearance is modest for a group living home.
The information contained in this application is correct to the best of my knowledge. I understand that
making false statements or being untruthful at any time will result in termination of Branch15 services.
*Signature: Signature
*Date: Date
Please return application to b15apps@branch15.org
or
PO BOX 1817 BETHANY, OK 73008