Women's Long-Term Housing Application
Applicant first name:Client first name
Applicant last name:Client last name
Today's Date:Date
Potential Entry Date Requested: Date
What is the name of the agency/facility that referred you or you are currently enrolled in? Client Referred By
What is a callback number you can be reached at?Text fieldText field
What is the name of your case manager?Text field
Applicant Contact Information
Street Address Client Address
City, State, Zip:
Client City
Client State
Client Zip
Phone Number: Client phone
Email: Client email
Date of Birth: Client birthdate
Marital Status: -Client marital status
Sex at Birth: Client gender
Ethnicity:Client ethnicity
Military History:Client veteran status
Emergency Contact Information
First and Last Name: Text field
Relationship to you: Text field
Phone Number: Text field
Medical History
Are you currently under the care of a physician?
Radio buttons
If yes, what is the name of your physician? Text field Phone#: Text field
Date of last doctor's appointment:Text field
Please list all medications you are currently taking or are prescribed to take: Medication
Please list all allergies: Client allergies
Current or past physical medical problems (please list all diagnoses)? Client health problems
Do you have any children? Radio buttons
If yes, where do they stay? Text field
Do you have a history of any of the following: Seizures, Diabetes, Tuberculosis (TB), Hepatitus, HIV/AIDS?Radio buttons
If yes, please list here (including dates): Paragraph
Have you ever suffered from depression, anxiety, or other serious mood disturbances?
Radio buttons
Any diagnosis of schizophrenia or other psychological disorder?
Radio buttons
If yes, please list here:Client diagnosis
What, if any, are your concerns about emotional/mental well-being?
Paragraph
Do you experience suicidal thoughts?
Radio buttons
Do you use tobacco?
Radio buttons
Alcohol / Drug History
Please list ALL mood-altering substance use/ drugs of choice:
Client substances of choice
Any family history of alcohol/drug use?
Radio buttons
Please list anything else you would like us to know about your drug/alcohol abuse history:
Paragraph
Treatment/Sobriety History
Most recent treatment facilities attended:TreatmentCenterHistory
Most recent sober living facility attended: SoberLivingHistory
Legal History
Please list all current/pending charges and past convictions including sexual offenses:
Charge:Text field
Date:Date
Sentence / Outcome: Text field
Charge:Text field
Date: Date
Sentence / Outcome: Text field
Do you have any Open 241 Kids or Child Protective Services cases?Radio buttons
If yes, what is your case manager's name and phone number? Text field
Education History
Highest grade completed: Text field
Degree/Diploma?
Radio buttons
GED:
Radio buttons
Employment History
Are you currently employed?
Radio buttons
If yes, please list the name of your employer: Text field Employer Phone# Text field
Please list your employment history here:
EmploymentHistory
Please review your application and make sure all fields have been filled out. Upon completion, please sign below and click "Submit Form". Your application will then be sent to the Housing Director for review. Please call 513-276-6304 opt#2 to follow up with the status of your application. Thank you.
Please sign your name below:
Signature
By continuing, you agree that your electronic signature is the legally binding equivalent of your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.