Mary Ellens Hearth Transitional Family Housing Program

Full Name *

Gender *

Ethnicity *

Race *

Date of Birth *

Age *

Social Security # *

Drivers License # *

Primary Language *

Religion

Referral Information

Referring Person/Agency *

Title *

Agency Address *

Address Line 1

City

State

Zip Code

Phone *

If referring agency is a shelter, how long has applicant resided in your facility?

Applicant Information

Present Address *

Address Line 1

City

State

Zip Code

Phone *

Marital Status *

Spouse/Ex-spouse Name *

Significant Other *

Do you own a car? *

If so, do you have current insurance on the car?

Do you have a valid, current Driver's license? *

Do you have any outstanding traffic tickets? *

Do you have any outstanding warrants? *

Name of Institutions to Which You Have Applied

Please list last three addresses, starting with most recent: (must cover last 5 years)

Address 1

Address Line 1

City

State

Zip Code

How long lived there

Monthly Rent

Address 2

Address Line 1

City

State

Zip Code

How long lived there 2

Monthly Rent 2

Address 3

Address Line 1

City

State

Zip Code

How long lived there 3

Monthly Rent 3

Highest grade completed in school

Did you graduate?

Yes
No

When?

If not, do you have a GED?

Yes
No

Date earned GED

Do you have a copy of your GED?

Yes
No

Are you currently in school?

Yes
No

What colleges/junior colleges/trade schools have you attended?

When?

List last three places of employment, starting with most recent:

Employer

Dates Worked

Address 1

Address Line 1

City

State

Zip Code

Position

Gross Monthly Pay

Employer 2

Dates Worked 2

Address 2

Address Line 1

City

State

Zip Code

Position 2

Gross Monthly Pay 2

Employer 3

Dates Worked 3

Address 3

Address Line 1

City

State

Zip Code

Position 3

Gross Monthly Pay 3

Please list all current sources of income and amount:

Source

Monthly Amount

Have you applied for public housing and/or Section 8 housing?

Yes
No

If yes, list date of application:

What is status (have a Voucher)?

Have you ever resided in public housing and/or Section 8 housing?

Yes
No

Where?

When?

Have you been evicted from private or public housing or Section 8?

Yes
No

If so, why were you evicted?

Explain any criminal history of you and/or any family members:

Are you currently involved in any legal action?

Yes
No

If yes, attorney?

Please explain and list case number and case name, if known:

Have you ever used alcohol or drugs?

Yes
No

If yes, when?

Have you ever been treated for substance abuse?

Yes
No

If yes, list place of treatment:

List dates of treatment:

Did you complete or graduate from the treatment program?

Yes
No

Are you in recovery?

Yes
No

If so, how long have you been in recovery?

Do you currently have a sponsor?

Yes
No

Name & Phone No. of Sponsor:

Do you currently have, or have you had at any time in the past, a DHR social worker?

Yes
No

If so, please list the Name of Worker

Phone

How did you or your family become involved with DHR? (Child Protective Services, TANF, JOBS, Foster Care?)

Have you been in the military?

No
Civilian
Active Duty
Retired

Are you the victim of domestic violence?

Yes
No

If yes, when was last incident:

Medical History

Weight

Height

Do you or have you ever had problems with (please check yes or no):

Heart Problems

Yes
No

Blood Pressure

Yes
No

Kidney/Urinary

Yes
No

Stomach/Digestive

Yes
No

Anemia

Yes
No

Stroke

Yes
No

Diabetes

Yes
No

Asthma/Allergies

Yes
No

Seizures

Yes
No

Lungs/TB

Yes
No

HIV / AIDS

Yes
No

Venereal Disease

Yes
No

Eyes

Yes
No

Personality Disorder

Yes
No

Hormonal Imbalance

Yes
No

Ear/Hearing Problems

Yes
No

Cancer

Yes
No

Bones/Joints

Yes
No

Nerves/Anxiety

Yes
No

Central Nervous System

Yes
No

Head Injury

Yes
No

Back Injury

Yes
No

Skin

Yes
No

Frequent Headaches

Yes
No

Vaginal Infections

Yes
No

Teeth / Mouth

Yes
No

Dyslexia

Yes
No

ADHD

Yes
No

Depression

Yes
No

Other

If you answered “yes” to any of the above, please list the condition and explain details below, including dates of injury/illness, treatment received, medications, doctor name and phone number, if you were hospitalized and where hospitalized:

Are you currently taking any medications? If so, please provide details:

Name of Medication

Daily Dosage

Condition

Dr.’s Name

Are you pregnant?

Yes
No

If so, what is due date?

Are you disabled?

Yes
No

Are you being treated for the disability?

What type of disability?

PLEASE PROVIDE FULL INFORMATION FOR EACH MINOR CHILD IN THE FAMILY.

Child’s Full Name

Date of Birth

Age

Social Security Number

Medicaid No.

Sex

Will child be residing with mother at MEH?

Yes
No

If not, why not?

Current School/Daycare Attending

Grade

Prior School/Daycare Attended

Has child repeated a grade or been held back a grade?

How many days of school did child miss last year?

Why?

What special needs or problems does this child have?

Has child been prescribed any medications?

Yes
No

If so, please list medication and diagnosis:

Is child currently taking medication(s) as prescribed? If not, why not?

CHILD 2

Child’s Full Name

Date of Birth

Age

Social Security Number

Medicaid No.

Sex

Will child be residing with mother at MEH?

Yes
No

If not, why not?

Current School/Daycare Attending

Grade

Prior School/Daycare Attended

Has child repeated a grade or been held back a grade?

How many days of school did child miss last year?

Why?

What special needs or problems does this child have?

Has child been prescribed any medications?

Yes
No

If so, please list medication and diagnosis:

Is child currently taking medication(s) as prescribed? If not, why not?

CHILD 3

Child’s Full Name

Date of Birth

Age

Social Security Number

Medicaid No.

Sex

Will child be residing with mother at MEH?

Yes
No

If not, why not?

Current School/Daycare Attending

Grade

Prior School/Daycare Attended

Has child repeated a grade or been held back a grade?

How many days of school did child miss last year?

Why?

What special needs or problems does this child have?

Has child been prescribed any medications?

Yes
No

If so, please list medication and diagnosis:

Is child currently taking medication(s) as prescribed? If not, why not?

PLEASE READ THE STATEMENT BELOW WHICH DEFINES A “HOMELESS” PERSON AND CHECK THE REASON YOU ARE CONSIDERED HOMELESS:

According to the U.S. Department of Housing and Urban Development Supportive Housing Program: Implementing Regulations, 24CFR, Part 583 (19960), homeless persons are those who are:

Sleeping in places not meant for human habitation, such as cars, parks, sidewalks, and abandoned buildings.
Sleeping in emergency shelters.
Living in transitional or supportive housing for homeless persons but whom originally came from streets or emergency shelters.
Being evicted within the week from private dwelling units and no subsequent residences have been identified and they lack the resources and support networks needed to obtain access to housing. (NOTE: This situation requires a letter or other document substantiating that eviction is cause of homelessness—please attach to this Application).
Being discharged within the week from institutions in which they have been residents for more than 30 consecutive days and no subsequent residences have been identified and they lack the resources and support networks needed to obtain access to housing.

Additional Comments/Details:

I certify that I have read the specific criteria for consideration as a resident of Mary Ellen’s Hearth, and that I meet these criteria. I have checked the homeless situation above which best applies to me.

I affirm that the foregoing information is true and complete to the best of my knowledge, information and belief. I understand that this form is only an application for consideration as a participant in Mary Ellen’s Hearth’s Transitional Housing Program, and that the submission of this application does not reserve housing nor in any way guarantee acceptance into the program. I authorize verification of all information and references given.

Signature *