Transitional Living Application

 

TRANSITIONAL LIVING APPLICATION
General Applicant Information

 

Date: Date

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

How did you hear about Madonna House or St. Elizabeth Lodge? Client referred by

 

Email: Client email Phone Number: Client phone

Birthdate: Client birthdate

Marital status: Client marital status

Other names you have used: Text field

Education (select highest level of education that applies):

Checkboxes

Have you ever served in the U.S. Military?:

Client veteran status

If yes, provide dates of service: Text field

Are you currently pregnant? 

Radio buttons

Baby’s due date: Client level/phase or birth date of youngest child: Text field

Please describe the issue(s) leading you to apply for housing at Catholic Charities: 

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FAMILY AND RELATIONSHIPS

Child #1:

Name: Contact 3 name

Relationship: Contact 3 type 

Birthdate: Contact 3 phone 

Living with you?

Radio buttons

Name of School or Daycare: Contact 3 email

Child #2:

Name: Contact 4 name 

Relationship: Contact 4 type

Birthdate: Contact 4 phone

Living with you?

Radio buttons

Name of School or Daycare: Contact 4 email

Child #3:

Name: Contact 5 name  

Relationship: Contact 5 type

Birthdate: Contact 5 phone

Living with you?

Radio buttons

Name of School or Daycare: Contact 5 email

Child #4:

Name: Contact 6 name

Relationship: Contact 6 type

Birthdate: Contact 6 phone

Living with you?

Radio buttons

Name of School or Daycare: Contact 6 email

Child #5:

Name: Contact 7 name

Relationship: Contact 7 type

Birthdate: Contact 7 phone

Living with you?

Radio buttons

Name of School or Daycare: Contact 7 email

Do you need to add additional children to this application?

Radio buttons

 

Please provide the following information concerning the youngest child's father:

Father's Name: Text field

Age: Text field

When was the last time you had contact with the child’s father?: Text field

What is the current status of your relationship with the child's father? (check one)

Radio buttons

Is there a history of drug abuse related to the child's father or his friends or relatives? (check one)

Radio buttons

Is there a history of physical or verbal abuse related to the child's father or his friends or relatives? (check one)

Radio buttons

Is the child's father planning to participate in the child's life? (check one)

Radio buttons

Do you have a custody arrangement with the child’s father?

Radio buttons

I have custody of my child on the following days:

Checkboxes

 

Please provide the following information concerning additional children's father (if different):

Father's Name: Text field

 

Age: Text field 

When was the last time you had contact with the child’s father?: Text field

What is the current status of your relationship with the child's father? (check one)

Radio buttons

Is there a history of drug abuse related to the child's father or his friends or relatives? (check one)

Radio buttons

Is there a history of physical or verbal abuse related to the child's father or his friends or relatives? (check one)

Radio buttons

Is the child's father planning to participate in the child's life? (check one)

Radio buttons

Do you have a custody arrangement with the child’s father?

Radio buttons

I have custody of my child on the following days:

Checkboxes

  

SPIRITUALITY/MOTIVATION -

Do you attend Church?

Radio buttons

If yes how often?:

Radio buttons

Do you consider yourself a member of a particular religion?

Radio buttons

Religion: Text field
Home Church: Text field

Residents of Madonna House and St. Elizabeth Lodge are required to attend church services of their choice on Sundays (or Saturday evening). Will you be able to make this commitment?

Radio buttons

 

APPLICANT RESIDENTIAL HISTORY 

Current Address: Client Address

City: Client City State: Client State Zip Code: Client Zip

Dates of Residency: Text field

Is current address the home of:(check one)

Radio buttons

If applicable, name of Friend/Relative/Motel/Shelter: Text field

Who lives with you at this address?
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Have you ever lived in other shelters or transitional housing, lived as an adult rent-free in another person’s home, and/or subsidized housing?:

Radio buttons

(If Yes, indicate below)

Shelter or Transitional Housing #1

Name: Sober living 1 name

City: Sober living 1 city State: Sober living 1 state 

Move-in Date: Sober living 1 admitted Move-out Date: Sober living 1 discharged

 

Shelter or Transitional Housing #2

Name: Sober living 2 name

City: Sober living 2 city State: Sober living 2 state

Move-in Date: Sober living 2 admitted Move-out Date: Sober living 2 discharged

 

Shelter or Transitional Living #3

Name: Sober living 3 name

City: Sober living 3 city State: Sober living 3 state 

Move-in Date: Sober living 3 admitted Move-out Date: Sober living 3 discharged

 

I have found myself homeless in the past:

Checkboxes


I have applied for:
Tulsa Public Housing-Date of application: Text field
Section 8 Voucher-Date of application:Text field
Subsidized apartment-Date of application:Text field

 

APPLICANT EMPLOYMENT HISTORY

Are you currently employed?

Radio buttons

Current Employer:

Employer: Employer 1 name Job title: Employment 1 position

Wage / Salary: Text field

Number of hours worked:Text field

Dates of employment - Started: Employment 1 started

Monthly Income: Employment 1 income 

 

Weekly Schedule:

Sunday: Text field

Monday: Text field

Tuesday: Text field

Wednesday: Text field

Thursday: Text field

Friday: Text field

Saturday: Text field

  

Previous Employment:

Employer: Employer 2 name Job title: Employment 2 position

Wage / Salary: Text field

Number of hours worked: Text field

Dates of employment - Started: Employment 2 started Ended: Employment 2 ended

Why did you leave? Employment 2 notes

 

Previous Employment:

Employer: Employer 3 name Job title: Employment 3 position

Wage / Salary: Text field

Number of hours worked: Text field

Dates of employment - Started: Employment 3 started Ended: Employment 3 ended

Why did you leave? Employment 3 notes

 

APPLICANT FINANCIAL HISTORY

Do you have any unpaid debts? (indicate amount)

Utilities $Text field

Rent $Text field

Bank loans $Text field

Car Loans $Text field

Education $Text field

Court fines $Text field

Child Support $Text field

Medical Bills $Text field

Other $Text field


In addition to employment income, do you receive any of the following? (Indicate amount.)

Disability/SSI $Text field

Child Support $Text field

Food stamps $Text field

WIC Text field

TANF $Text field

  

APPLICANT HEALTH HISTORY

Are you currently pregnant? 

Radio buttons

Due date: Text field

Are there any complications with this pregnancy? Are you considered High Risk?

Radio buttons

If yes, please describe: 

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Are you enrolled in SoonerCare? 

Radio buttons

Are you currently under a physician’s care? 

Radio buttons


If yes, indicate the following:

Physician Name: Contact 9 name

Contact 9 type

Phone Number: Contact 9 phone
Address:(Street) (City) (State) (Zip Code)

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If you are not pregnant, what is the birth date of your youngest child? Text field

Pediatrician Name: Text field

Phone Number: Text field

Address: (Street) (City) (State) (Zip) (Include area code)

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Medical Issues:

Please list any medical conditions/disabilities with which you have been diagnosed or for which you are
receiving treatment:

Health problems: Client health problems

Please list any medical conditions/disabilities which were not provided in the drop downs above:
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Please list any medical conditions/disabilities with which your child has been diagnosed or for which your child is receiving treatment:

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Mental Health:


1. Have you or any individual listed above seen a mental health provider in the
past 10 years?

Radio buttons

2. Are you experiencing any of the following symptoms/problems? (please check all that apply)

Checkboxes

Please list any mental health conditions with which you have been diagnosed or for which you are receiving treatment:

Client diagnosis

Are you currently receiving treatment?

Radio buttons

Have you ever been hospitalized due to one of these conditions?

Radio buttons

If yes, where? 

Treatment Center Name: Treatment center 1 name

City: Treatment center 1 city State: Treatment center 1 state

Admission: Treatment center 1 started Discharge: Treatment center 1 ended

Treatment Center Name: Treatment center 4 name

City: Treatment center 4 city State: Treatment center 4 state

Admission: Treatment center 4 started Discharge: Treatment center 4 ended

 

Please list any mental health conditions with which any family member listed above has been diagnosed and/or is receiving treatment:

Paragraph

 

Please list any medications that you are currently taking:

Medication #1

Medication: Medication 1 name Dosage: Medication 1 dosage

Condition for which medication prescribed: Text field

Medication #2

Medication: Medication 2 name Dosage: Medication 2 dosage

Condition for which medication prescribed: Text field

Medication #3

Medication: Medication 3 name Dosage: Medication 3 dosage

Condition for which medication prescribed: Text field

Medication #4

Medication: Medication 4 name Dosage: Medication 4 dosage

Condition for which medication prescribed: Text field

 Medication #5

Medication: Medication 5 name Dosage: Medication 5 dosage

Condition for which medication prescribed: Text field

  

Please note: the use of Medical Marijuana, with or without a prescription, is not allowed in the Catholic Charities Transitional Living program. Phentermine weight loss pills also are not permitted.

  

SUBSTANCE USE HISTORY

Tobacco:

1. Do you currently use tobacco products?

Checkboxes

Alcohol

1. Have you previously used alcohol? 

Radio buttons

If yes, age of first use: Text field

2. Have you used alcohol in the past 30 days? 

Radio buttons

3. Frequency of alcohol use (check one):

Radio buttons

4. When you use alcohol, how many drinks to you usually consume (check one):

Radio buttons

5. Have you previously been involved in a program to help you stop using alcohol?

Radio buttons

6. If yes, indicate the name of the program and provide approximate dates of attendance:

Text field

Start Date: Text field 

End Date: Text field

Drug Use

1. Have you previously used illegal drugs? 

Radio buttons

If yes, age at first use: Text field

2. If yes, please list:

Client substances of choice

3. Have you used in the past 30 days?

Radio buttons

4. Approximate date of last use: Recovery history 1 relapse date

Drug(s) used: Text field

5. Describe frequency of use (check one):

Radio buttons

6. Have you been involved in a program to help you quit using drugs?

Radio buttons

7. If yes, indicate the name of the program and provide approximate dates of attendance:

Treatment Center #1:  Treatment center 2 name

City: Treatment center 2 city  State: Treatment center 2 state

Admission: Treatment center 2 started Discharge: 

Treatment Center #2:  Treatment center 3 name

City: Treatment center 3 city  State: Treatment center 3 state

Admission: Treatment center 3 started Discharge: Treatment center 3 ended

 

  

APPLICANT LEGAL HISTORY

1. Have you ever been arrested and/or charged with a crime?

Radio buttons

2. If yes, please indicate the charge(s) and approximate date(s) of those charges:

Charge #1: Text field

Date: Text field

Conviction? 

Radio buttons

Charge #2: Text field

Date: Text field

Conviction?

Radio buttons

Charge #3: Text field

Date: Text field

Conviction?

Radio buttons

Charge #4: Text field

Date: Text field

Conviction?

Radio buttons

 

3. Are you currently on probation?

Radio buttons

4. Do you currently or have you ever had a case before DHS? 

Radio buttons
If yes, please describe the circumstances of your case, and indicate whether and how it was resolved or
whether it is still pending. 

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DHS Caseworker Name: Contact 8 name

Phone Number: Contact 8 phone

 

Are you or have you ever been affected by any of these situations? (Select all that apply)

Checkboxes
Please describe: 

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Is this a current issue?:

Radio buttons

When was the last time these incidents occurred? Text field

  

Please answer the following reflective questions:

1. Why have I chosen Catholic Charities Transitional Living?

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2. What do I hope to accomplish as a resident of Catholic Charities Transitional
Living?

Paragraph

 

Emergency Contact:

1. Name: Contact 1 name Phone: Contact 1 phone

Type: Contact 1 type Email: Contact 1 email

2. Name: Contact 2 name  Phone: Contact 2 phone

Type: Contact 2 type  Email: Contact 2 email

 

All of the above information is true and correct to the best of my knowledge.

Applicant Signature:

Signature

 

Required Documentation at time of Interview:

Current copies of paystubs for past 30 days

Proof of pregnancy

If admitted, these documents are required at the time of move-in:

Birth Certificate for each individual
Social Security cards for each individual
Copy of driver’s license or valid State I.D. for each person as applicable
SoonerCare or other health insurance cards

So that we may serve you better:

Please list any immediate needs for food, clothing (including sizes), or other items: 

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