Contact Form Test Transitional Housing Program Application Holly Place 21573 Foothill Blvd, Suite 210, Hayward, CA 94541 Tel : (510) 733-6800 Fax : 510 733-6801 PERSONAL INFORMATION (Please Print Legibly) Name (required) Application Date (required) Primary Address City State Zip Code Gender Home Phone Cell Work Phone E-Mail Date Of Birth Age Social Security Number Referral Resource Ethnic identity: Circle the proper code for your ethnic group, circle all that apply (OPTIONAL) Select an optionAmerican Indian or Alaskan NativeCubanLaotianBlack, non-Hispanic, including AfricanPuerto RicanVietnameseMexican American, Mexican, ChicanoOther LatinoFilipinoCentral AmericanChineseWhiteSouth AmericanJapanesePacific IslanderKorean Do you have children? If yes how old are they and are they living with you? Are you currently on probation or have you ever been on probation? Name of current/last social worker Phone Country Name of current/ last probation officer Phone County Email EMERGENCY CONTACT INFORMATION Name Relationship Address City State Zip Code Home Phone Cell Phone Work Phone REFERRAL/AGENCY SOURCE Name of person who referred you to transitional housing Relationship Agency Work Phone E-Mail EDUCATION AND EMPLOYMENT Have you obtained any of the following? GED High School Diploma Certificate of Completion What best describes your current education status? Enrolled in High School Enrolled in Community College or 4 year university Enrolled in GED program Enrolled in Adult Education Program (completing High school diploma) If not enrolled in school, are you interested in enrolling in school? YesNo Do you currently or did you previously have an IEP? YesNo If enrolled in school, what school? What best describes your employment status? Employed Part-time Employed Full-time Not currently employed Current Employer Position If not employed what is your primary source of income? WELLNESS Which of the following describes your general emotional state?(Check All That Apply) StableUnstableA littledepressedVery depressedUnstableNone of them History of any of the following? (Check All that Apply) Suicidal thoughts, intentionsSuicide attemptsUncontrollable fits of rageHomicidal thoughts/intentions Have you ever had a mental health diagnosis? YesNo If yes, please specify Do you currently have a therapist? YesNo If yes, Name Phone We will not contact your therapist without your permission Do you have a psychiatrist? YesNo If yes, Name Phone We will not contact your psychiatrist without your permission Do you receive SSI/SSDI YesNo If yes, what do you receive SSI/SSDI for? Please list any medical conditions past or present Please list any mental health issues past or present Please list all prescription medication that you have been prescribed Have you ever been hospitalized? If so, please explain Do you drink alcohol? YesNo If yes, how often? Do you currently use drugs? YesNo If yes, which drugs and how often? Do you smoke cigarettes? YesNo If yes, how many per day? Have you ever been in a treatment program for substance abuse? YesNo If yes, name of the program and dates of treatment? Is your family network (circle one) Select An OptionVery supportivesupportivenot supportiveno contact Is your social network (circle one) Select An OptionVery supportivesupportivenot supportiveno contact Have you ever been arrested? YesNo A. If yes, for what? B. What was the result? LOCATION AND HOUSING What neighborhood/city best describes the location of the following people or things? Your Job Your School Your Social Network Where do you want to live Do you feel you have safe and stable housing? YesNo If no, do you need emergency shelter? YesNo What best describes your current living situation? Renting own or shared housing(paying rent) Living with relative or other person in stable housing(rent free) THP-Plus program Specifyk Unstable housing situation(couch surfing with relatives, friends or other people) Emergency shelter, homeless or other unstable housing (street, car, etc) Institutionalized (just exited hospital, jail, mental health facility with no place to go) Specify Other Do you require reasonable housing accommodation due to a disability? YesNo Do you know how to cook? Do you know how to clean? Have you ever had a roommate? YesNo Was the experience positive or negative? (Explain) Do you have experience with making and keeping a monthly budget? YesNo Are you able to pay bills on time? YesNo Do you own a credit card? YesNo Do you have a bank account? YesNo If yes what type? CheckingSavings Do you owe money on school loans? YesNo Do you know how to use public transportation? YesNo Do you have any pets? YesNo If yes, what kind and how many? {{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting…
