Program Application

Timothy House Transitional Living Program

Davids House Permanent Supportive Housing
Dr. Maurice J. Hart Veterans Program
Name:

DOB

Current Address

City

Age

Sex

Race

State

Vet* Social Security #

Hisp.

Zip code

Can we leave a message with the phone number listed above? Yes

Phone

No

Please check all of the benefits that you currently receive:

Medicaid

Medicare

FIP

SSI

SSD

IVA

Unemployment

Food Stamps

General Assistance

Workmans Compensation

Pensions

Retirement Acc.

Alimony

Child Support

Section 8 DO Waiver

Do you have monthly income?

Yes No

If yes, how much montly income:__________

Source of income:_____________________

Have you ever lived in your own apartment or home?

Are you a United States citizen?

Yes

Are you a veteran of the United States?

Yes No

Yes

No

No

If you answered yes above, what branch did you serve in? __________________ Discharge Type:________

What is your marital status?

Single

Married

Seperated Divorced

Widowed

Not Married

Please list the name and ages of your children:

Name:

Check if you have custody:

The Christian Worship Center D.B.A. New Visions Homeless Services

- Revised 06/2012

Where do they live:

Do you suffer from a disability?

Mental Disability Physical Disability Substance Abuse

If you answered yes above, please list the names, addresses, and phone numbers of your current
service providers: (please use additional pages and attach to back of application if necessary)
Position:

Address / Phone:

Name:

Psychologist / Counselor
Social Worker / Case Manager
Financial Manager
Other:
Other:
Other:

Please list all you current medications and dosages: (please list over the counter medications, herbs, and supplements)
Medications

Dosage (How Much/How Often)

Prescribing Doctor:

Please list any counseling/mental health agencies that you have received treatment from in the past, including in-patient hospitalizations, out-patient hospitalizations, outpatient psychiatry, counseling, and/
or case management: (please use additional pages and attach to back of application if necessary)
Facility Name and Location:

Substance Treated:

The Christian Worship Center D.B.A. New Visions Homeless Services

- Revised 06/2012

Dates:

Have you used any substances in the past year? (please check all that apply)
Alcohol

Amphetamines

Cocaine/Crack

Hallucinogenic Opiates (i.e. Heroine, Morphine, etc.)

Marijuana

Inhalants

Prescription Drug Abuse

Barbiturates (i.e. Seconal, Nembutal, etc.)

Non Prescribed Benzodiazepines (i.e. Valium, Xanax, etc.)
If you have used any of these in the past 30 days, please list below:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Have you ever been convicted of a felony or other crime?

Yes

No

If you answered yes above, please list below:

Conviction:

Location:

Date:

Are you currently awaiting trial or sentencing? Yes No

If yes, please list the details:__________________________________________________________________
Are you currently on parole/probation?

Yes

No

If yes, please list the name, address, and phone number of parole officer(s):____________________________
________________________________________________________________________________________
Are you currently listed on the sex offenders registry: Yes No

Offense:____________________

Please list current day structure: (check all that apply)

Work full time

Work part time

Irregular Work

Volunteer

Student

PSR/ Therapeutic

Day Program

None

List the name, address, phone number of place of employment or other day structure:____________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
What is the highest level of education completed: ______________________________________________
The Christian Worship Center D.B.A. New Visions Homeless Services

- Revised 06/2012

Have you been homeless before?

Yes

No

If yes, how long?_____________________

Please give a detailed answer to the questions listed below:

Describe the circumstances for being homeless at this time: (include where you are currently residing)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

What are you currently doing to change your present situation:

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Other information you would like us to know:

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

All applications are processed in the order received. Thank you for taking the time to apply for one of our programs. Not all applicants are admitted into program.
Someone will contact you as soon as possible concerning your application process and review. Thank You.

The Christian Worship Center D.B.A. New Visions Homeless Services

- Revised 06/2012