TRANSITIONAL LIVING APPLICATIONGeneral Applicant Information
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 fieldEducation (select highest level of education that applies):
Have you ever served in the U.S. Military?:
Client veteran status
If yes, provide dates of service: Text field
Are you currently pregnant?
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:
FAMILY AND RELATIONSHIPS
Name: Contact 3 name
Relationship: Contact 3 type
Birthdate: Contact 3 phone
Living with you?
Name of School or Daycare: Contact 3 email
Name: Contact 4 name
Relationship: Contact 4 type
Birthdate: Contact 4 phone
Name of School or Daycare: Contact 4 email
Name: Contact 5 name
Relationship: Contact 5 type
Birthdate: Contact 5 phone
Name of School or Daycare: Contact 5 email
Name: Contact 6 name
Relationship: Contact 6 type
Birthdate: Contact 6 phone
Name of School or Daycare: Contact 6 email
Name: Contact 7 name
Relationship: Contact 7 type
Birthdate: Contact 7 phone
Name of School or Daycare: Contact 7 email
Do you need to add additional children to this application?
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)
Is there a history of drug abuse related to the child's father or his friends or relatives? (check one)
Is there a history of physical or verbal abuse related to the child's father or his friends or relatives? (check one)
Is the child's father planning to participate in the child's life? (check one)
Do you have a custody arrangement with the child’s father?
I have custody of my child on the following days:
Please provide the following information concerning additional children's father (if different):
Age: Text field
Do you attend Church?
If yes how often?:
Do you consider yourself a member of a particular religion?
Religion: Text fieldHome 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?
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)
If applicable, name of Friend/Relative/Motel/Shelter: Text field
Who lives with you at this address?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?:
(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:
I have applied for:Tulsa Public Housing-Date of application: Text fieldSection 8 Voucher-Date of application:Text fieldSubsidized apartment-Date of application:Text field
APPLICANT EMPLOYMENT HISTORY
Are you currently employed?
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
Sunday: Text field
Monday: Text field
Tuesday: Text field
Wednesday: Text field
Thursday: Text field
Friday: Text field
Saturday: Text field
Employer: Employer 2 name Job title: Employment 2 position
Number of hours worked: Text field
Dates of employment - Started: Employment 2 started Ended: Employment 2 ended
Why did you leave? Employment 2 notes
Employer: Employer 3 name Job title: Employment 3 position
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
Food stamps $Text field
WIC Text field
TANF $Text field
APPLICANT HEALTH HISTORY
Due date: Text field
Are there any complications with this pregnancy? Are you considered High Risk?
If yes, please describe:
Are you enrolled in SoonerCare?
Are you currently under a physician’s care?
If yes, indicate the following:
Physician Name: Contact 9 name
Contact 9 type
Phone Number: Contact 9 phoneAddress:(Street) (City) (State) (Zip Code)
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)
Please list any medical conditions/disabilities with which you have been diagnosed or for which you arereceiving 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:
1. Have you or any individual listed above seen a mental health provider in thepast 10 years?
2. Are you experiencing any of the following symptoms/problems? (please check all that apply)
Please list any mental health conditions with which you have been diagnosed or for which you are receiving treatment:
Are you currently receiving treatment?
Have you ever been hospitalized due to one of these conditions?
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:
Please list any medications that you are currently taking:
Medication: Medication 1 name Dosage: Medication 1 dosage
Condition for which medication prescribed: Text field
Medication: Medication 2 name Dosage: Medication 2 dosage
Medication: Medication 3 name Dosage: Medication 3 dosage
Medication: Medication 4 name Dosage: Medication 4 dosage
Medication: Medication 5 name Dosage: Medication 5 dosage
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
1. Do you currently use tobacco products?
1. Have you previously used alcohol?
If yes, age of first use: Text field
2. Have you used alcohol in the past 30 days?
3. Frequency of alcohol use (check one):
Radio buttons4. When you use alcohol, how many drinks to you usually consume (check one):
Radio buttons5. Have you previously been involved in a program to help you stop using alcohol?
6. If yes, indicate the name of the program and provide approximate dates of attendance:
Start Date: Text field
End Date: Text field
1. Have you previously used illegal drugs?
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?
4. Approximate date of last use: Recovery history 1 relapse date
Drug(s) used: Text field
5. Describe frequency of use (check one):
6. Have you been involved in a program to help you quit using drugs?
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?
2. If yes, please indicate the charge(s) and approximate date(s) of those charges:
Charge #1: Text field
Date: Text field
Charge #2: Text field
Charge #3: Text field
Charge #4: Text field
3. Are you currently on probation?
4. Do you currently or have you ever had a case before DHS?
Radio buttonsIf yes, please describe the circumstances of your case, and indicate whether and how it was resolved orwhether it is still pending.
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)
Is this a current issue?:
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?
2. What do I hope to accomplish as a resident of Catholic Charities TransitionalLiving?
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.
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: