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LivingWorks Ventures Lodge Pre-Application

Date______/______/______

Referent______Tel______-______-______

Applicant Legal Name______Tel______-______-______

Date of birth _____/______/______Age ______Social Security number ______-______-______

Current address______

Move in date______

Previous address______

Dates of occupancy from ______/______/______to ______/______/______(Shelters included)

Have you stayed in one of the following shelters within the past three months? (Circle)

  • Salvation Army
  • People Serving People
  • Park Avenue
  • People Inc. Hennepin House
  • St. Anne’s
  • Other

Do you have written shelter verification from the above shelter? (Circle) YESNO

Is your primary nighttime residence a public or private place not meant for regular sleeping accommodations, including a car, park, abandoned building, airport, train station or camping grounds? YES NO

Are you exiting an institution where you have resided for 90 days or less and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution? YES NO

Are you fleeing from domestic violence, dating violence, sexual assault, stalking, or other dangerous life-threatening conditions that relate to violence against you? YES NO

Do you have any of the following? (Circle)

Birth CertificateYES NO

Social Security card YESNO

Drivers LicenseYESNO

Minnesota ID cardYES NO

Metro Mobility cardYESNO

Tribal ID cardYES NO

US Armed ForcesYESNODD-214YESNO

Health insuranceYESNOMedical Insurance Name______

Medical Insurance Address______

Medical Insurance ID ______

Medical Insurance Group Number______

Secondary Insurance YESNOSecondary Insurance Name______

Secondary Insurance Address______

Secondary Insurance ID______

Secondary Insurance Group Number______

Gov Assistance YESNOCase number______

County Case Manager YESNOName______

Address______

Phone/Fax number______

Supportive ServicesYESNOName______

Address______

Phone/Fax number______

Waivered ServicesYESNOProgram name______

PsychologistYESNOName______

Address______

Phone/Fax number______

PsychiatristYESNOName______

Address______

Phone/Fax number______

Do you need psychiatric services YESNOConcern______

Current PhysicianYESNOName______

Address______

Phone/Fax number______

Do you need medical attentionYESNO Concern______

Latest Tuberculosis testingDate_____/_____/______Results (Circle)POSITIVENEGATIVE

Previous hospitalizationsDate____/____/____Procedure______

Date____/____/____Procedure______

Previous hospitalizations, Cont.Date____/____/____Procedure______

Date____/____/____Procedure______

Previous Substance Use Disorder/CD Treatment

Date ____/____/____Location______

Date ____/____/____Location______

Date ____/____/____Location______

Date ____/____/____Location______

Current DentistYESNOName______

Address______

Phone/Fax number______

Do you need dental attention?YESNOConcern______

GuardianYESNOName______

Address______

Phone/Fax number______

Rep PayeeYESNOName______

Address______

Phone/Fax number______

Probation OfficerYESNOName______

Address______

Phone/Fax number______

Parole Officer YESNOName______

Address______

Phone/Fax number______

Pending legal issues?YESNOViolation______

Are you on court commitment?YESNO Detail______

Are you a registered sex offender?YESNODetail______

Do you have housing restrictions?YESNODetail______

Pending Workman’s Comp Case?YESNONotes (QRC)______

Emergency ContactYESNOName______

Address______

Phone/Fax number______

Substance Use Disorder/CD?YESNO Diagnosis______

When was your last use of recreational drugs or alcohol? ______/______/______

Physical limitations?YESNOMedical Diagnosis______

Medical Equipment?YESNOItem description______

Are you independent with the medical equipment?YESNO

Assistance needed______

Mental Health condition? YESNOPsychiatric Diagnosis______

Current medication list required, see check-list.

Have you ever hit your head? YESNODate______/______/______

Circumstances______

______

Outcome______

Do you have children under the age of 18?YESNO

Do you have custody?YESNOUnsupervised visitation rightsYESNO

Do you hear voices? YESNOFrequency______

Have you tried to hurt or killing yourself? YESNOFrequency______

Do you have thoughts of hurting or killing yourself?YESNOFrequency ______

List your last three jobs with the most recent listed first

  • Employer______Dates ______/______/______

Duties______

Reason for leaving______

  • Employer______Dates ______/______/______

Duties______

Reason for leaving______

  • Employer______Dates______

Duties______

Reason for leaving______

Do you have you High School DiplomaYESNOLast grade completed ______

Do you have your GEDYESNOWould you like to go back to schoolYESNO

Additional education ______

Are you looking for employmentYESNOFULL-TIMEPART-TIME

Do you receive RSDIYESNOAmount ______

Do you receive SSIYESNOAmount ______

Do you receive retirement benefitsYESNOAmount ______

Do you receive Veterans benefitsYESNOAmount ______

Do you think you may be eligible for Social Security benefits YESNO

Explaination______

______

Do you have a vehicleYESNO Transportation method ______

Will you sign a 12 month leaseYESNO

Will you give written 30 day notice when you leave YESNO

Application check-list:

-Current Medication List

-Diagnostic Assessment / Neuropsychological Evaluation

-In order to process your application the above documentation along with the completed application is necessary.

-Fax application to 763-479-4372
Attention: Gina Chamberlin/Colleen Larson

-Questions or concerns 763-479-4898