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

 

Email: Client email Phone Number: Client phone

Birthdate: Client birthdate

School: Client school

Marital status: Client marital status

Other names you have used: Text field

Education: (check highest level of education that applies)

Checkboxes

Educational Goal: Text field

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

Client veteran status

If yes, provide dates of service: Date to Date
Are you currently pregnant? 

Radio buttons
Baby’s due date: Date or birth date of youngest child: Date

 

FAMILY AND RELATIONSHIPS

List all children:

First Name Last Name Gender: Birth Date? Living with you? School/Daycare
Text field Text field Text field Date Radio buttons Text field
Text field Text field Text field Date Radio buttons Text field
Text field Text field Text field Date Radio buttons Text field
Text field Text field Text field Date Radio buttons Text field 

Additional children can be added at the time of interview.

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

Father's Name: Text field

Address include:(Street) (City) (State) (Zip Code):

Paragraph

Age: Text field

 

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

Paragraph

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

Address include:(Street) (City) (State) (Zip Code):

Paragraph

Age: Text field 

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

Paragraph

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

 

1. Is there a family history of addictions?

Radio buttons

2. If yes, please describe:
Paragraph
3. How would you describe your relationship with your children?

Checkboxes

Paragraph


4. What do you and your family do for fun?
Paragraph


5. Identify the people who are supportive of you and your family: (Check all that apply)

Checkboxes

 

SPIRITUALITY/MOTIVATION -

Do you attend Church?

Radio buttons

If yes how oftern?:

Radio buttons

Do you consider yourself a member of a particular religion?

Radio buttons

Religion: Text field
Home Church: Text field


As part of living at Madonna House or St. Elizabeth Lodge, you are required to attend church services of your choice on Sundays (or
Saturday evening). Will you have trouble agreeing to those terms? 

Radio buttons


If yes, please explain:

Paragraph

 

APPLICANT RESIDENTIAL HISTORY 

Address: Client Address

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

Dates of Residency: Date to  Date
Is current address the home of:(check one)

Radio buttons


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

Who lives with you at this address?
Name: Text field Relationship: Text field

Name: Text field Relationship: Text field

Prior Addresses
(Please include information for the 5 years prior to submitting this application)


1) Previous address:
(Street) (City) (State) (Zip): Text field

Landlord: Text field Phone: Text field
Dates of Residency: Date to Date
Who lived with you at this address?
Name: Text field Relationship: Text field

Name: Text field Relationship: Text field

Name: Text field Relationship: Text field


2) Previous address: Text field
(Street) (City) (State) (Zip)
Landlord: Text field Phone: Text field
Dates of Residency: Date to Date
Who lived with you at this address?

Name: Text field Relationship: Text field

Name: Text field Relationship: Text field

Name: Text field Relationship: Text field

 

(If additional space is needed, please use the box below):

Paragraph

 

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

Description: Sober living 1 description

Address: Sober living 1 address

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

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

Estimated length of stay: Sober living 1 estimated length of stay

Reason for discharge: Sober living 1 reason for discharge

Shelter or Transitional Housing #2

Name: Sober living 2 name

Description: Sober living 2 description

Address: Sober living 2 address

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

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

Estimated length of stay: Sober living 2 estimated length of stay

Reason for discharge: Sober living 2 reason for discharge

Shelter or Transitional Living #3

Name: Sober living 3 name

Description: Sober living 3 description

Address: Sober living 3 address

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

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

Estimated length of stay: Sober living 2 estimated length of stay

Reason for discharge: Sober living 3 reason for discharge

I have found myself homeless in the past:

Checkboxes


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

 

 

APPLICANT EMPLOYMENT HISTORY

(Please include information for the 5 years prior to submitting this application)

 

Current Employer:

If you are not currenntly employed, please check here:

Checkboxes

Employer: Employer 1 name Job title: Employment 1 position

Address: Text field

Phone: Text field

Supervisor: Text field

Wage / Salary: Text field

Number of hours worked :Text field

Dates of employment - Started: Employment 1 started Ended: Employment 1 ended

Monthly Income: Text field    Pay Days: Text field

Type: Employment 1 type

Notes: Employment 1 notes

Weekly Schedule:

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

Address: Text field

Phone: Text field

Supervisor: Text field

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

Address: Text field

Phone: Text field

Supervisor: Text field

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? (check all that apply)

Checkboxes Disability/SSI $Text field

Checkboxes Child Support $Text field

Checkboxes Food stamps $Text field

Checkboxes WICText field

Checkboxes TANF Text field

 

 

APPLICANT HEALTH HISTORY

Are you currently pregnant? 

Radio buttons

Due date: Date
Are there any complications with this pregnancy? Are you considered High Risk?

Radio buttons
If yes, please describe:

Paragraph


Are you enrolled in SoonerCare? 

Radio buttons

Are you currently under a physician’s care? 

Radio buttons


If yes, indicate the following:

Physician Name: Text field
Address:(Street) (City) (State) (Zip Code) Text field

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

Pediatrician Name: Text field
Address: (Street) (City) (State) (Zip) (Include area code) Text field

Phone: Text field

 

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:
Paragraph

Please list any medical conditions/disabilities with which your child has been diagnosed or for which your
child is receiving treatment:

Paragraph

 

Mental Health:


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

Radio buttons

If yes, please provide the following information regarding those providers:

Name: Text field

Address: (Street) (City) (State) (Zip): Text field

Phone: Text field

Name: Text field

Address: (Street) (City) (State) (Zip): Text field

Phone: Text field

 

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:

 

Condition Date of Diagnosis Receiving Treatment? Hospitalizations due to condition? Include dates:
Client diagnosis Date Radio buttons

Radio buttons

Date

Client diagnosis Date Radio buttons

Radio buttons

Date

Client diagnosis Date Radio buttons

Radio buttons

Date

Client diagnosis Date Radio buttons

Radio buttons

Date

 

Please list any mental health conditions with which any family member listed on Page 1 of this Application
has been diagnosed and/or is receiving treatment:

Condition Date of Diagnosis Receiving Treatment? Hospitalizations due to condition? Include dates:
Client diagnosis Date Radio buttons

Radio buttons

Date

Client diagnosis Date Radio buttons

Radio buttons

Date

Client diagnosis Date Radio buttons

Radio buttons

Date

Client diagnosis Date Radio buttons

Radio buttons

Date

 

Please complete the following chart concerning medications currently prescribed to you:

Medication #1

Medication: Medication 1 name Dosage: Medication 1 dosage

Condition for which medication prescribed: Text field

Start date of taking medication: Text field

Quantity: Medication 1 quantity 

Frequency: Medication 1 frequency MD: Medication 1 md

Notes: Medication 1 notes

Medication #2

Medication: Medication 2 name Dosage: Medication 2 dosage

Condition for which medication prescribed: Text field

Start date of taking medication: Text field

Quantity: Medication 2 quantity

Frequency: Medication 2 frequency MD: Medication 2 md

Notes: Medication 2 notes

Medication #3

Medication: Medication 3 name Dosage: Medication 3 dosage

Condition for which medication prescribed: Text field

Start date of taking medication: Text field

Quantity: Medication 3 quantity 

Frequency: Medication 3 frequency MD: Medication 3 md

Notes: Medication 3 notes

Medication #4

Medication: Medication 4 name Dosage: Medication 4 dosage

Condition for which medication prescribed: Text field

Start date of taking medication: Text field

Quantity: Medication 4 quantity 

Frequency: Medication 4 frequency MD: Medication 4 md

Notes: Medication 4 notes

Medication #5

Medication: Medication 5 name Dosage: Medication 5 dosage

Condition for which medication prescribed: Text field

Start date of taking medication: Text field

Quantity: Medication 5 quantity 

Frequency: Medication 5 frequency MD: Medication 5 md

Notes: Medication 5 notes

 

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.

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

Paragraph 

 

SUBSTANCE USE HISTORY

Tobacco:
1. Have you ever used any forms of tobacco?

Checkboxes
2. If yes, what form(s) of tobacco have you use in the past? (check all that apply)

Checkboxes

3. How many times on an average day do you use tobacco? Text field
4. Have you ever been involved in a program to help you quit using tobacco?

Radio buttons

5. If so, which self-help group was used? Text field

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:

Paragraph

 

Drug Use

1. Have you previously used illegal drugs? 

Radio buttons

If yes, age at first use: Text field
2. If yes, please list:
Paragraph
3. Have you used in the past 30 days?

Radio buttons

4. Approximate date of last use: Text field

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

Name: Treatment center 1 name

Admitted: Treatment center 1 started Discharged: Treatment center 1 ended

Notes: Treatment center 1 notes

Type: Treatment center 1 type

Reason for discharge: Treatment center 1 reason for discharge

Treatment Center #2

Name: Treatment center 2 name

 

Admitted: Treatment center 2 started Discharged: Treatment center 2 ended

Notes: Treatment center 2 notes

Type: Treatment center 2 type

Reason for discharge: Treatment center 2 reason for discharge

 

 

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/Crime Date of Charge Conviction? 
Text field Date Radio buttons
Text field Date Radio buttons
Text field Date Radio buttons
Text field Date Radio buttons

3. Are you currently or have you ever been 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. 

Paragraph

 

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

Radio buttons

Please describe: 

Paragraph

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?

Paragraph

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

Paragraph

 

Emergency Contacts: 

Name: Contact 8 name Phone: Contact 8 phone

Type: Contact 8 type Email: Contact 8 email

Name: Contact 9 name Phone: Contact 9 phone

Type: Contact 9 type Email: Contact 9 email

Name: Contact 10 name Phone: Contact 10 phone

Type: Contact 10 type Email: Contact 10 email

 

PLEASE READ CAREFULLY AND INITIAL THE FOLLOWING

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

Applicant Signature:

Signature

Date: Date

 

Required Documentation:

Checkboxes Current copies of paystubs for past 30 days

Checkboxes Proof of pregnancy

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

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

So that we may serve you better:

Please list any immediate needs for food, clothing or other items: 

Paragraph

 

Name: Pant size: shirt size: shoe size: Bra size: underweare size:
Text field Text field Text field Text field Text field Text field
Text field Text field Text field Text field Text field Text field
Text field Text field Text field Text field Text field Text field
Text field Text field Text field Text field Text field Text field
Text field Text field Text field Text field Text field Text field
Text field Text field Text field Text field Text field Text field

 

 

  

AmericanChecked, Inc.

Investigative / Consumer Report Disclosure &; Release

 

In connection with my employment/volunteerism or application for employment (including contract for services
and volunteer work), an investigative consumer report and consumer reports, which may contain public record
information, may be requested from AMERICANCHECKED, INC. These reports may include the following types
of information: names and dates of previous employers, reason for termination of employment, work experience,
accidents, academic history, professional credentials, drugs/alcohol use, information relating to your character,
general reputation, personal characteristics, mode of living, educational background, or any other information
about you which may reflect upon your potential for employment gathered from any individual, organization,
entity, agency, or other source which may have knowledge concerning any such items of information. Such
reports may contain public record information concerning your driving record, workers’ compensation claims,
credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such
records.


I authorize AMERICANCHECKED, INC. to prepare a consumer report or investigative consumer report about me
for employment/volunteer-related purposes. I have been provided a copy of the summary of the rights of the
consumer pursuant to the Fair Credit Reporting Act (FCRA).


I hereby fully release and discharge AMERICANCHECKED, INC., their respective affiliates, subsidiaries,
directors, officers, employees, agents and attorneys thereof, and each of them, and any individual, organization,
entity, agency, or other source providing information to AMERICANCHECKED, INC. from all claims and damages
arising out of or relating to any investigation of my background for employment/ volunteer purposes. This release
is valid for all federal, state, county and local agencies, authorities, previous employers, military services and
educational institutions.


AMERICANCHECKED, INC. is authorized to disclose all information obtained to the requesting entity for the
purpose of making a determination as to my eligibility for employment/volunteerism, promotion or any other lawful
purpose. I agree that such information, and my employment history, may be supplied to AMERICANCHECKED,
INC. If hired or contracted, this authorization shall remain on file and shall serve as ongoing authorization for the
procurement of consumer reports at any time during my employment/volunteerism or contract period.


By signing below, I certify that I have read and fully understand this release, that prior to signing I was given an
opportunity to ask questions and to have those questions answered to my satisfaction, and that I executed this
release voluntarily and with the knowledge that the information being released could affect my being hired, my
employment/volunteerism, or my eligibility for promotion.

 


Today’s Date Date

Signature

Signature
Print your full name Client first name Client last name


For purposes of gathering this information, I agree to supply the following information, which may be required by
law enforcement agencies and other entities for positive identification purposes when checking records. It is
confidential and will not be used for any other purpose.


Print other last names you have used Text field

List States and Counties of Residence for the past: 3 years / 5 years / 7 years /10 years

State Text field City/CountyText field FromText field toText field
StateText field City/CountyText field FromText field toText field
StateText field City/CountyText field FromText field toText field
StateText field City/CountyText field FromText field toText field
Home AddressText field
CityText field StateText field Text field
Social Security No.Text field Date of Birth Client birthdate
Driver’s License No.Text field State Issuing LicenseText field

Sex: Client gender

Race: Client race

You have the right to receive, upon your written request within a reasonable period of time, (not to exceed 30
days) a complete and accurate disclosure of the nature and scope of the investigation requested. You have the
right to make a request to AMERICANCHECKED, INC., upon proper identification, to request the nature and
substance of all information in its files on you at the time of your request, including the sources of information, and
the recipients of any reports on you that AMERICANCHECKED, INC. has previously furnished within the two-year
period preceding your request. AMERICANCHECKED, INC. may be contacted by mail at 4870 S. Lewis Ave.
Ste. 211, Tulsa, Oklahoma, 74105, or by phone at
(800) 975-9876.


(Oklahoma, Minnesota, or California residents requesting a copy of their credit report will receive a copy of the
report pulled directly from Trans Union LLC)

 

CheckboxesOklahoma Applicants Only: I request a copy of any credit report requested on me.
CheckboxesMinnesota Applicants Only: I request a copy of any consumer report requested on me.

 

Notice to California Applicants
Under California law, the consumer reports we order on you for employment purposes within the State of California are defined as
investigative consumer reports. These reports may contain information on your character, general reputation, personal characteristics and
mode of living. Under section 1786.22 of the California Civil Code, you may view the file maintained on you by AMERICANCHECKED, INC.
during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication
services, by appearing at AMERICANCHECKED, INC. in person, by mail, or by telephone. AMERICANCHECKED, INC. may be contacted by
mail at 4870 S. Lewis St Ste. 211 Tulsa, Oklahoma, 74105, or by phone at (800) 975-9876. The agency is required to have personnel
available to explain your file to you and the agency must explain to you any coded information appearing in your file. If you appear in person, a
person of your choice may accompany you, provided that this person furnishes proper identification.
I request to receive a free copy of any investigative consumer report ordered on me by checking this box.

(California applicants only)
Please complete the following:
Name Client first name Client last name
Address Text field
City Text field Zip Text field

 

Company Name: Text field  Location No.: Text field