Family Promise Mat-Su

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Family Promise Mat-Su

Guest Application

Referred by: ______Date applying______

Date entering program______

Discharge Date______

Guest Phone #’s______

Names of Household MembersD.O.B. SSN M/F

______/___/______-_____-______

Marital Status of Adults: ______

Pregnancy:

Is anyone in the family pregnant? Yes/No/Don’t know Who?______

Other children? Y/N Where are they now? ______

ID for Adults:

Name: ______Type: ______

Emergency Contact Person: ______Relationship ______

Address ______Phone______

Relatives in Town? Y/N Who? ______Phone______

Do you have shelter for tonight? Y/N

Most Recent Housing: Address: ______

What has been your community of residence for the last 6 months?______

What was the zip code of your last permanent address (where you lived for at least 90 days)? ______

If you have not lived at the above address for at least 6 months where did you live before? City______State______Length of time there______

Length of time in Mat Su Valley:______

Where did you sleep last night?______

How long have you been homeless? ______

Housing Status:

_____Imminent risk of losing housing _____Literally homeless

_____Housed and at risk of losing housing_____Stably housed

How Many Times Have You Been Homeless?

_____First time_____1-2 times in the past year

_____More than 2 times in the past year

_____4 times in the past 3 years

Prior Living Situation:

____ Subsidized housing_____Rental by client with VASH subsidy

_____Rental by Client, no housing subsidy_____Rental by client with other (non- VASH) housing subsidy

_____Transitional housing for homeless persons _____Substance abuse treatment facility of detox center

_____Owned by client, no housing subsidy_____Place not meant for habitation (car, woods, tent, street, park, etc.)

_____Foster care or foster care group home_____Jail, prison, or juvenile detention facility

_____Hospital (non-psychiatric) _____Psychiatric hospital or other psychiatric facility

_____Permanent housing for formerly homeless persons

_____Staying or living in a family member’s room, apartment or home

_____Staying or living in a friend’s room, apartment, or home

_____Emergency shelter, including hotel or motel paid with a voucher

_____Hotel or motel paid for without an emergency voucher

_____Other_____Don’t know_____Refused

Length of Stay at Residence immediately prior to entering Family Promise program:

_____One week or less _____More than a week, but less than a month

_____One year or longer _____Don’t know

_____More than three months, but less than one year

_____Refused

Immediate Reason for Homelessness:

____ Own home evicted

____ Own home being foreclosed

____ Shared or rental property being foreclosed____ Own home-unable to pay rent

____ Lived with others/forced to leave____ Disaster: ______

____ Moved- unable to find affordable housing or employment

Secondary Reason for Homelessness: (Check all that apply)

____ Medical Problems____ Family Dissolution

____ Benefits Stopped____ Lost Job

____ Other: ______

Ever lived in a shelter before:Yes/No When/Where?______

Do you have a car? Yes/No

Make/Model ______License Plate ______Insurance? Yes/No

Do you have any Pets? Yes/No Immunizations up-to-date? Yes/No

Number and species: ______

Plan for Care: ______

Education-Children

NameGradeSchoolTeacher

______

Income Source Past Month:Amount: Receiving Now?

____ None

____ TANF______

____ Social Security ______

____ Unemployment Benefits______

____ Worker’s Compensation______

____ Veteran’s Benefits______

____ Food Stamps______

____ Child Support______

____ Other______

Ever filed for bankruptcy: Yes/No Details: ______

Assets (amount):

______Cash

______Savings/Checking

______Real Estate: ______

______Automobile______Other: ______

Debts (amount/type):

______

Military Status:

(Note: To be considered a veteran, according to the HUD definition, a person has to have served in a war zone or be on active military duty. A person in the National Guard or the Reserves are not considered on active military duty unless they are called up.)

Military Veteran? Yes/NoIf yes, which branch? ______

Have you served in a war zone or are you currently on active military duty? Yes/No

Employment History

1. Adult: ______Employed Now? Yes/No

Where: ______Telephone #:______

Job title: ______Hours/ week: ______

If unemployed, how long since last job? ______

If unemployed, what keeps you from working now? ______

Ever terminated from a job? Yes/No Explain: ______

Length of longest employment: ______

What type of job skills/experience do you have? ______

______

Education: (Highest level completed – HLC)

______Presently in H.S. – HLC ______Dropped out of H.S. - HLC

______High School Diploma______G.E.D.

______Vocational Training______Some College- HLC _____

______Completed College- Degree ______

2. Adult: ______Employed Now? Yes/No

Where: ______Telephone #:______

Job title:______Hours/ week: ______

If unemployed, how long since last job? ______

If unemployed, what keeps you from working now? ______

Ever terminated from a job? Yes/No Explain: ______

Length of longest employment: ______

What type of job skills/experience do you have? ______

______

Education: (Highest level completed – HLC)

______Presently in H.S. – HLC ______Dropped out of H.S. - HLC

______H.S. Diploma______G.E.D.

_____ Vocational Training______Some College- HLC _____

_____ Completed College- Degree ______

Has there been any domestic violence in your history? Y/N (if yes, call AFS or AWAIC)

Legal History: (Any omissions will result in dismissal from FPMS)

Adult: ______(name) [Where, when, what charge(s)]

Arrests: ______

______

Convictions: ______

______

Parole/Probation Officer: ______Phone:______

Pending Charges: ______

______

Civil Proceedings Underway:______

______

Child Protection (OCS) History: Past/Present/ None/Details:______

______

Adult: ______(name) [Where, when, what charge(s)]

Arrests: ______

______

Convictions: ______

______

Parole/Probation Officer: ______Phone:______

Pending Charges:______

______

Civil Proceedings Underway:______

______

Child Protection (OCS) History: Past/Present/None/Details:______

______

Health/Special Needs:

Name: ______Medical Coverage: ______

Allergies: ______

Medications/Dosages:______

Medical Conditions: ______Last Medical Visit:______

Physician: ______Phone: ______

Immediate Needs: Medical Yes/No Dental Yes/No Vision Yes/No

Comments:______

Name: ______Medical Coverage: ______

Allergies: ______

Medications/Dosages: ______

Medical Conditions: ______Last Medical Visit:______

Physician: ______Phone: ______

Immediate Needs: Medical Yes/NoDental Yes/No Vision Yes/No

Comments:______

Name: ______Medical Coverage: ______

Allergies: ______

Medications/Dosages: ______

Medical Conditions: ______Last Medical Visit: ______

Physician: ______Phone: ______

Immediate Needs: Medical Yes/NoDental Yes/No Vision Yes/No

Comments:______

Name: ______Medical Coverage: ______

Allergies: ______

Medications/Dosages: ______

Medical Conditions: ______Last Medical Visit:______

Physician: ______Phone: ______

Immediate Needs: Medical Yes/NoDental Yes/No Vision Yes/No

Comments: ______

Are children’s immunizations up-to-date? Yes/No/Don’t know

Do you or does anyone in your family have a disability of a long duration? Y/N

If yes, please give the name/s of the person/s with the disability:______

______

Please indicate the type of disability and if more than one person is disabled, please include their initials by the type of disability that they have:

______Physical

______Developmental

______Mental

Substance Abuse History/Issues: (Any omissions will result in dismissal from FPMS)

Does anyone in your family have a history of substance abuse?

NameSubstanceTreatmentHow long clean/dry?

______

Comments: ______

______

Mental Health:

Is anyone in your family receiving Mental Health Services? ______

Do they receive Alaska Mental Health Trust Benefits? Y/N

NameWhereMedication?DiagnosisLast Visit

______

Comments: ______

______

Agency(ies) currently involved with your family:

AgencyContactPhoneIssue

______

I confirm that the information I have provided for this Application is true, accurate and complete to the best of my knowledge. If for any reason all or part of this Application are falsified I will be dismissed from the program. I further give consent for Family Promise Mat-Su to complete a criminal background check prior to my acceptance into the network. I understand that Family Promise has the right to refuse to serve clients upon their discretion.

Guest Signature:______Date:______

FOR STATISTICS ONLY:

(Note: Ethnicity and Race are not the same thing. Please answer both the ethnicity question and the race question below.)

Ethnicity:

Guest #1:_____Hispanic/Latino_____Non Hispanic/Non Latino

_____Don’t know_____Refused

Guest #2:_____Hispanic/Latino_____Non Hispanic/Non Latino

_____Don’t know_____Refused

Guest #3:_____Hispanic/Latino_____Non Hispanic/Non Latino

_____Don’t know_____Refused

Guest #4:_____Hispanic/Latino_____Non Hispanic/Non Latino

_____Don’t know_____Refused

Race: Put a #1 by your primary race, and a #2 by your secondary race. If they are the same put a #1 and #2 on the same line.

Guest #1: _____White _____Asian ____American Indian or Alaska Native

_____Black or African American Primary Alaska Native Corporation

_____Native Hawaiian or Other ______

Pacific Islander Secondary Alaska Native Corporation

_____Don’t Know ______

_____Refused _____Other

Guest #2: _____White _____Asian ____American Indian or Alaska Native

_____Black or African American Primary Alaska Native Corporation

_____Native Hawaiian or Other ______

Pacific Islander Secondary Alaska Native Corporation

_____Don’t Know ______

_____Refused _____Other

Guest #3: _____White _____Asian ____American Indian or Alaska Native

_____Black or African American Primary Alaska Native Corporation

_____Native Hawaiian or Other ______

Pacific Islander Secondary Alaska Native Corporation

_____Don’t Know ______

_____Refused _____Other

Guest #4: _____White _____Asian ____American Indian or Alaska Native

_____Black or African American Primary Alaska Native Corporation

_____Native Hawaiian or Other ______

Pacific Islander Secondary Alaska Native Corporation

_____Don’t Know ______

_____Refused _____Other

Primary Language spoken in the family______

To be filled out by FPMS Office Staff:

Criminal Background Check:

Guest:______Date:______Agency:______Results______

______

Guest:______Date:______Agency:______Results______

______