Te Veo House Application
I am applying for the *
Client facility
Name *
Client first name Client middle name Client last name
Today's Date *
Date
Date of Birth *
Client birthdate
Social Security Number *
SSN
Cell Phone Number *
Client phone
Email
Client email
Do you have a valid ID? *
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ID Number if Applicable:
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Current Housing
Which of the following best describes your current housing situation? *
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Other:
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Are you currently looking for/interested in longer-term housing? *
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How long has this been your housing situation? *
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When will you be moving out of your housing? *
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Emergency Contact
Emergency Contact Name *
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Phone *
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Email *
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Address *
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Family Situation
What is your current situation? *
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Name of spouce or partner (if applicable)
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Are you currently pregnant? *
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What is your due date (if applicable)?
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Do you have children? *
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How many children do you have (if applicable)?
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Please share more information about your children:
| |
Name |
Age |
Gender |
Current Custody Status |
| 1 |
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| 2 |
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| 5 |
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If applicable, are you seeking reunification with any of your children? If so, when?
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Employment
What is your current employment status? *
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What is your most recent work experience or desired occupation? *
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Current Employer if applicable. Please include name of company, contact name, phone number and annual income.
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What is your current annual income? *
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Please share any additional income sources below including TANF, SSI/SDI, Unemployment, and/or other supports.
| |
Amount $ |
Type |
Case # |
| 1 |
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| 2 |
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What is your current level of education? *
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Other:
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More Information
What do you feel is the cause of your present difficulties? *
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How can we best support you in working through these challenges? *
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Have you lived in any Providence Network or Open Door Ministries homes before? *
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If yes, which home/s and when?
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What do you think are the barriers getting in the way of you obtaining housing? *
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Please share two goals you have for yourself. *
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How committed are you to making the necessary changes to address the root cause of your housing barriers? *
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Substance Use & Addictions
Are you currently sober? *
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When did you last use? *
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Do you consider yourself an addict? *
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Are you currently experiencing withdrawal symptoms? *
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If yes, please specify:
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What are your drug(s) of choice?
Client substances of choice
| |
Substance You Use |
How Much |
How Often |
Last Used |
Where do you typically use? |
| 1 |
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| 2 |
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What is your longest time of sobriety? *
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What do you believe has helped you stay sober in the past? *
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Do you believe you have other addictions? (eating, unhealthy relationships, spending, gambling, hoarding, etc.) *
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If yes, please specify:
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Have you ever participated in a recovery group, meeting or program? *
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If yes, which programs or groups have you participated in?
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How can we best support you in recovery? *
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Medical & Mental Health Needs
Do you have a current Tuberculosis card? *
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Do you have any disabilities or medical conditions that keep you from working or limit the type of work you do? *
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If yes, please explain:
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Are you currently being treated, or have you been treated in the past six months, for a mental health or medical condition? *
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If applicable please list all mental health concerns/diagnosis: *
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Health Problems, please select all that apply: *
Client health problems
Please list all current medications: *
Medication
If you are receiving mental health are and are willing to give us permission to contact them, please list here:
Therapist/Clinician
Are you currently using medical marijuana? *
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If yes, are you willing to find an alternative medication to help?
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How can we best help you manage your conditions? *
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Legal History
Are you applying for this program because of a court order? *
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Have you ever been arrested for a violent crime or domestic assult? *
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Have you ever been convicted? *
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Please share more about any prior charges.
| |
Charges |
Date |
Status |
Misd/Felony/Class |
| 1 |
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| 2 |
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| 3 |
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Have you ever been incarcerated? *
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Are there any charges pending? *
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Are you currently on probation? *
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Are you currently on parole? *
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Do you have any outstanding fees, fines, or restitution? *
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Total amount owed:
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What is your current payment amount?
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Please list all requirements for parole/probation (meetings, classes, UAs, BAs, court appearances):
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Background Check:
I authorize Open Door Ministries and/or its agents to make an independent investigation of my background, references, character, past employment, education, credit history, criminal or police records, and motor vehicle records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualificiations for my acceptance now and, if applicable, during the tenure of my stay with Open Door Ministries. I release Open Door Ministires and/or its agents and any person or entity, which provides information pursuant to this authorization, form any and all liabilities, claims or law suits in regards to the information obtained form any and all of the above referenced sources used.
Signature:*
Signature
Date:*
Date
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Signature
By continuing, you agree that your electronic signature is the legally binding equivalent to 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.
I attest that I have answered all questions accurately and honestly to the best of my recollection.
Applicant's Name: *
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Applicant's Signature: *
Signature
Date: *
Date
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