SCM – Careers & MORE works with adults who are homeless, at risk, and economically disadvantaged parents of minor children, teaching them to overcome barriers, secure gainful employment, and attain self-sufficiency.
1. Applicant’s full name 2. SSN
3. Referring agency 4. Contact person
5. Phone # 6. Fax # 7. Email 8. Date issued / /
9. Referral source: Self Gov. Agency: ______________ Hospital or medical clinic staff
Street outreach/church worker Alcohol or drug treatment program Police/Probation/Parole/SRC
Emergency/transitional shelter staff Other social service staff, specify: Supportive Housing/Public housing waiting list
Psychiatric in/outpatient facility _______________________________ Other __________________________________
Applicant Info: 10. Address Apt./room # 11. Phone #
12. City/Zip: / 13. Housing is: Temporary Permanent
14. Housing: Streets Halfway house Supportive housing Emergency shelter Transitional housing Own/rent Relative/friend
Other 15. How long at this location? 16. Are you receiving housing assistance? Yes No
17. Gender: M F 18. DOB: _____/_____/_____ 19. Last grade completed: ______________ 20. Marital Status: M S
21. Dependents: Spouse Children # _____ Other # 22. Dependents living with applicant # ________
23. Currently employed? Yes No 24. Monthly household income $__________ 25. On parole? No Yes IDOC # _____________
26. Race (check all appropriate): Black White non-Hispanic Hispanic Native American Asian Slavic Other ______________
27. Applicant special needs: addiction treatment anger management/domestic violence/abuse learning disability/literacy Ed/GED
diagnosed disability health/dental care clothing transportation housing criminal record other _____________________
28. Is program completion required for continuation of your services? Yes No 29. Do you require a weekly status report? Yes No
NOTE: Status reports are generated by email or fax only. Please provide complete information if you wish to have a status report forwarded to you.
As a representative of the referring agency I certify, to the best of my knowledge, the above information is true and accurate.
REQUIRED: Signature – Agency Representative/Case Worker Date
PLEASE FAX THIS COMPLETED REFERRAL TO SHELTER CARE MINISTRIES APPLICANT MUST CALL FOR AN APPOINTMENT.
FOR PLES OFFICE USE ONLY
29. Intake assessment scheduled for / / @ ______ AM / PM 30. Scheduled for PEC on: ______/______/_____
31. Programs eligible for: Homeless At Risk UW Other (specify) __________________________________________ NONE
32. Not enrolled: Refused Did not show Did not meet requirements (specify) _______________________________ Unknown