Be Able
Transitional Housing Intake
Please fill out the following information to the best of your ability.
This application is long, so please make sure you set aside enough time to complete each page.
If needed, you can save your progress and return to your application another time.
General Information
First Name:
Client first name
Middle Name:
Client middle name
Last Name:
Client last name
Contact Information
Phone Number:
Client phone
Email:
Client email
Details
Birthdate:
Client birthdate
State of Birth:
Client State
Race:
Client race
Ethnicity:
Client ethnicity
Social Security #:
SSN
Are you a US Citizen?
Radio buttons
Primary Language Spoken:
Text field
Do you have a valid Drivers License?
Radio buttons
Do you have any driving restrictions? If so, please list them below.
Text field
Are you a Veteran?
Radio buttons
Branch of Service:
Text field
Type of Discharge:
Text field
Emergency Contacts
Contact #1
Contact
Family History
What is your marital status?
Client marital status
Name of spouse or significant other:
Text field
Describe your relationship with your spouse or significant other:
Paragraph
Names and ages of any children:
Paragraph
Describe your relationship with your children:
Paragraph
Please describe your relationship with other family members:
Mother:
Paragraph
Father:
Paragraph
Step-Mother:
Paragraph
Step-Father:
Paragraph
Guardian:
Paragraph
Siblings:
Paragraph
Please describe the type of discipline used in your home:
Paragraph
Criminal Background & History
How many times have you been in jail?
Text field
What dates?
Text field
List all crimes for which you have been indicted and/or convicted, and length of time served for each:
Paragraph
Have you ever been charged or convicted of a sex crime?
Radio buttons
If yes, please explain:
Paragraph
Have you ever been charged with or convicted of domestic violence?
Radio buttons
If yes, please explain:
Paragraph
Do you currently have a restraining order against you?
Radio buttons
If yes, when does it expire?
Text field
Who file the order?
Text field
What is your relationship to them?
Text field
Have you been affiliated with any gangs?
Radio buttons
If yes, which gangs, what was your age, and for how long were you affiliated:
Paragraph
Do you have any unresolved conflicts with people outside of prison?
Radio buttons
If yes, please explain:
Paragraph
Are you on parole?
Radio buttons
How long will you be on parole?
Text field
Are you on probation?
Radio buttons
Probation
Criminal History
Social Support
Are you willing to have a Be Able mentor for accountability?
Radio buttons
If no, please explain:
Paragraph
Do you own a vehicle?
Radio buttons
If you are accepted into the Be Able Housing Program, are you willing to abide by the transitional plan and complete all required program materials?
Radio buttons
Groups
What groups or opportunities do you plan to be involved in? Please be specific.
Checkboxes
Paragraph
Social Support
Please list the name and relationship of up to 4 individuals who you will utilize for a positive support system (i.e., family member, friend, pastor, mentor, etc.)
Name & Relationship:
Text field
Name & Relationship:
Text field
Name & Relationship:
Text field
Name & Relationship:
Text field
Interests
What sports, interests and/or hobbies do you enjoy?
Paragraph
Finances & Employment Information
Financial Situation
Do you currently have a job?
Radio buttons
If yes, what are the duties of your position?
Paragraph
How many hours do you work per week?
Text field
What is your salary or hourly pay rate?
Text field
What is the amount of your retention funds?
Text field
What is the amount of your spendable funds?
Text field
Do you have any deductions sent out?
Radio buttons
If yes, what are the deductions?
Text field
If yes, what are the amounts?
Text field
Please list and detail the amount of all outstanding fines, fees, and payments:
Child Support:
Text field
Department of Motor Vehicles:
Text field
Restitution
Text field
To Whom?
Text field
Other:
Text field
What other financial support do you have?
Paragraph
Do you plan to apply for Supplemental Social Security Income (SSI)?
Radio buttons
If yes, why are you applying for SSI?
Text field
Have you applied for SSI before?
Radio buttons
If yes, when did you apply?
Text field
How do you plan to pay for fees and other financial obligations?
Paragraph
If you are accepted into the Be Able Housing Program, will you be committed to:
Living within your financial means?
Radio buttons
Adhering to a budget developed by Be Able?
Radio buttons
Ensuring that you pay rent or other obligations promptly?
Radio buttons
Finances & Employment Information
Employment History
Are you currently employed?
Radio buttons
Position:
Text field
Employer:
Text field
Location of employer:
Text field
Do you have physical or mental limitations that would prevent you from working?
Radio buttons
If yes, please explain:
Paragraph
How will you respond when you are seeking employment and find a job, but BAHP decides the job is not in your best interest?
Paragraph
EmploymentHistory
Education
EducationHistory
What specific training do you have?
Paragraph
Apprenticeship(s)?
Paragraph
Spiritual Life
This section is only used to help us understand you better.
The information you provide will not be used in any determinations for your acceptance into this program.
Do you consider yourself a spiritual person?
Radio buttons
What does spirituality mean for you?
Paragraph
What are some of the struggles you have in living out your beliefs?
Paragraph
Do you attend regular studies and/or worship services?
Radio buttons
Do you have a “life motto” or a verse that has special meaning to you?
Paragraph
Medical History
Medical Conditions/Issues
Please check any that apply to you and give an explanation where applicable.
Client health problems
(click the white box again to select more than one option)
Checkboxes
Paragraph
Checkboxes
Checkboxes
Checkboxes
Please Specify: Text field
Checkboxes
Please Specify:
Paragraph
Other Medical Information
Disabilities including finger, hand, arm, leg problems, etc., including amputation:
Paragraph
Back Problems:
Paragraph
Joint Replacements:
Paragraph
Please describe any other medical conditions:
Paragraph
Please list all surgeries and the year the surgery was done:
Paragraph
Please list any health problems you are presently experiencing and/or any procedures you need:
Paragraph
Please select all known allergies:
Paragraph
What are your plans to meet your medical needs?
Paragraph
When was your last physical examination?
Text field
Medications
Please list all medications you currently take.
Medication
Mental Health & Addiction History
Mental Health
Have you ever been diagnosed with or treated for mental illness?
Radio buttons
If yes, what was the diagnosis?
Client diagnosis
What medications were prescribed at that time?
Paragraph
When did this condition begin?
Text field
Do you ever hear "voices" or have other auditory hallucinations?
Radio buttons
If yes, when did this begin?
Text field
Do you ever have visual hallucinations?
Radio buttons
If yes, when did this begin?
Text field
Have you ever been diagnosed with Obsessive Compulsive Disorder (OCD) or have OCD tendencies?
Radio buttons
If yes, please explain:
Paragraph
Have you ever had suicidal thoughts or attempted suicide?
Radio buttons
If yes, please explain:
Paragraph
Counseling History
Counseling History
Mental Health & Addiction History
Addiction History
Client substances of choice
(click the white box again to select more than one option)
Alcohol
Have you ever abused or been addicted to alcohol?
Radio buttons
Beginning Age:
Text field
Type(s) of alcohol:
Text field
When was the last time you drank alcohol?
Text field
Drugs
Have you ever abused or been addicted to drugs?
Radio buttons
Beginning Age:
Text field
Type(s) of drug:
Text field
When was the last time you used?
Text field
Other Addictions
Have you ever struggled with other types of addiction?
Radio buttons
If yes, what type?
(check all that apply)
Checkboxes
Text field
Recovery
What triggers cause you to resort back to addictive behaviors?
(for example: association with certain individuals/places, stress, unresolved anger, fear, etc.)
Paragraph
Please select all programs completed to address your addictions:
Checkboxes
Text field
Please select any groups/meetings you currently attend:
Client kinds of meetings attended
Are you willing to participate in programs that address addictive behavior?
Radio buttons
If no, please explain:
Paragraph
Clinical Treatment History
Have you ever been to Inpatient or Outpatient Drug & Alcohol Treatment?
Radio buttons
If yes, please detail below:
TreatmentCenterHistory
Mental Health & Addiction History
Trauma History
Have you ever been sexually abused?
Radio buttons
Age:
Text field
How Long?
Text field
By Whom?
Text field
Have you ever been sexually abused?
Radio buttons
Age:
Text field
How Long?
Text field
By Whom?
Text field
Have you experienced suicide, murder, or other significant losses in your family?
Radio buttons
If yes, please explain:
Paragraph
Please list any professional counseling you've had:
Paragraph
Acknowledgement & Submission
By signing below, I understand that the information submitted is accurate and descriptive to the best of my ability.
Name:
Text field
Signature or Initials:
Signature
Today's Date:
Date