Community Youth Outreach Intake Form
LAST NAME
Your answer
FIRST NAME
Your answer
MIDDLE NAME
Your answer
OTHER NAMES USED AND DATES
Your answer
DATE OF BIRTH - YEAR
MM
/
DD
/
YYYY
AGE
DO YOU HAVE A BIRTH CERTIFICATE?
CURRENT ADDRESS
Your answer
CURRENT ZIPCODE
Your answer
CELL PHONE
Your answer
Cell phone -Safe to leave a message ?
WORK PHONE
Your answer
WORK PHONE - Safe to leave a message ?
OTHER PHONE
Your answer
Safe to leave a message ?
EMAIL
Your answer
SOCIAL SECURITY NUMBER - LAST 4 DIGITS
Your answer
HAS ANYONE ELSE USED YOUR SOCIAL SECURITY NUMBER?
IF YES, WHO?
Your answer
IS YOUR CURRENT SOCIAL SECURITY NUMBER A REISSUED NUMBER?
IF YES, WHEN WAS IT REISSUED?
Your answer
ID OR DRIVERS LICENSE NUMBER
Your answer
ID OR DRIVERS LICENSE STATE
Your answer
ID OR DRIVERS LICENSE EXPIRATION DATE
Your answer
DO YOU HAVE A VALID DRIVING PERMIT?
DO YOU HAVE A VALID DRIVERS LICENSE?
HAS YOUR LICENSE EVER BEEN SUSPENDED?
DO YOU HAVE A CAR?
IF YES, MAKE AND MODEL OF CAR
Your answer
HOW LONG HAVE YOU BEEN AT YOUR CURRENT ADDRESS?
LIST THE LAST 3 ADDRESS AND APPROXIMATE DATES
If a shelter, give name. If homeless, state None
Your answer
HAVE YOU EVER LIVED IN A SHELTER?
IF YES, WHERE?
Your answer
WHAT PLACEMENTS DID YOU HAVE IN FOSTER CARE?
IF RELATIVE PLACEMENT, WHAT DATES?
Your answer
IF GROUP HOME PLACEMENT, WHAT DATES?
Your answer
IF FOSTER PLACEMENT, WHAT DATES?
Your answer
HAVE YOU EVER BEEN EVICTED OR ASKED TO LEAVE A LIVING ARRANGEMENT?
IF YES, EXPLAIN
Your answer
HAVE YOU EVER BEEN DENIED A REFUND ON A RENTAL DEPOSIT FOR PROPERTY DAMAGE OR HAD TO PAY PENALTIES?
IF YES, EXPLAIN
Your answer
WILL YOU RESPECT THE RIGHTS OF ROOMMATES AND NEIGHBORS?
GUARDIAN/ PARENT/ FOSTER PARENT/ CAREGIVER - NAME
Your answer
GUARDIAN/ PARENT/ FOSTER PARENT/ CAREGIVER - RELATIONSHIP
Your answer
GUARDIAN/ PARENT/ FOSTER PARENT/ CAREGIVER - ADDRESS
Your answer
GUARDIAN/ PARENT/ FOSTER PARENT/ CAREGIVER - CURRENT STATUS OF RELATIONSHIP
Your answer
GUARDIAN/ PARENT/ FOSTER PARENT/ CAREGIVER - PHONE
Your answer
GUARDIAN/ PARENT/ FOSTER PARENT/ CAREGIVER - EMAIL
Your answer
RELATIONSHIP STATUS
IF OTHER, EXPLAIN
CURRENT SPOUSE/PARTNERS NAME
Your answer
CURRENT SPOUSE/PARTNERS PHONE
Your answer
CURRENT SPOUSE/PARTNERS EMAIL
Your answer
LENGTH OF RELATIONSHIP
Your answer
CURRENT SPOUSE/PARTNERS EMPLOYER
Your answer
ANY PREVIOUS MARRIAGES
IF YES, HOW DID IT END?
ARE YOU PREGNANT?
WHEN IS YOUR DUE DATE?
Your answer
HOW MANY CHILDREN DO YOU HAVE?
DO YOU HAVE CUSTODY OF YOUR CHILDREN?
HOW MANY LIVE WITH YOU FULLTIME?
NAME OF FIRST CHILD
Your answer
AGE OF FIRST CHILD
OTHER PARENT OF FIRST CHILD
Your answer
DOES THIS CHILD LIVE WITH YOU?
NAME OF SECOND CHILD
Your answer
AGE OF SECOND CHILD?
OTHER PARENT OF SECOND CHILD?
Your answer
DOES THIS CHILD LIVE WITH YOU?
NAME OF THIRD CHILD?
Your answer
AGE OF THIRD CHILD?
OTHER PARENT OF THIRD CHILD
Your answer
DOES THIS CHILD LIVE WITH YOU?
NAME OF FOURTH CHILD?
Your answer
AGE OF FOURTH CHILD?
OTHER PARENT OF FOURTH CHILD?
Your answer
DOES THIS CHILD LIVE WITH YOU?
NAME OF FIFTH CHILD?
Your answer
AGE OF FITH CHILD?
OTHER PARENT OF FIFTH CHILD
Your answer
DOES THIS CHILD LIVE WITH YOU?
WHICH CHILDREN HAVE BEEN IN CHILD PROTECTIVE SERVICES?
Your answer
LIST ONE PERSON WHO GIVES YOU SUPPORT AS A FAMILY OR FRIEND
Your answer
RELATIONSHIP
Your answer
WHERE DO THEY LIVE?
Your answer
GIVE A SECOND PERSON WHO GIVES YOU SUPPORT AS A FAMILY OR FRIEND
Your answer
RELATIONSHIP
Your answer
WHERE DO THEY LIVE?
Your answer
GIVE A THIRD PERSON WHO GIVES YOU SUPPORT AS A FAMILY OR FRIEND
Your answer
RELATIONSHIP
Your answer
WHERE DO THEY LIVE?
Your answer
WHO IS YOUR MEDICAL INSURANCE PROVIDER?
Your answer
WHAT IS YOUR PRIMARY PHYSICIAN OR CLINIC?
Your answer
WHO SHOULD BE CONTACTED IN CASE OF A MEDICAL EMERGENCY?
Your answer
PHONE NUMBER
Your answer
RELATIONSHIP
Your answer
ARE YOU CURRENTLY BEING TREATED FOR ANY MEDICAL CONDITIONS?
EXPLAIN EACH MEDICAL CONDITION
Your answer
ANY PAST MEDICAL PROBLEMS?
IF YES, PLEASE EXPLAIN
Your answer
ARE YOU CURRENTLY BEING TREATED FOR ANY MENTAL HEALTH ISSUES?
PLEASE EXPLAIN
Your answer
WHAT ARE YOUR CURRENT MEDICATIONS AND DOSAGES?
Your answer
DO YOU CURRENTLY USE MARIJUANA?
DO YOU CURRENTLY USE ILLEGAL DRUGS?
WHICH DRUGS?
HOW OFTEN?
DID YOU USE ILLEGAL DRUGS IN THE PAST?
WHICH DRUGS?
HOW OFTEN?
DO YOU SMOKE OR USE OTHER TOBACCO PRODUCTS?
DO YOU DRINK ALCOHOL?
HOW OFTEN?
WHAT DO YOU DRINK?
HOW MUCH AT A TIME?
HAVE YOU EVER RECEIVED SUBSTANCE ABUSE TREATMENT
IF YES, WHERE?
Your answer
IF YES, WHEN?
Your answer
WHAT TYPE TREATMENT?
DO YOU HAVE DENTAL PROBLEMS?
DO YOU HAVE A DENTIST?
DO YOU HAVE DENTAL INSURANCE?
DO YOU WEAR GLASSES?
ARE YOU CURRENTLY EMPLOYED?
WHERE DO YOU WORK?
Your answer
IF YES, WORK ADDRESS
Your answer
WORK POSITION
Your answer
HOW LONG AT THIS POSITION?
HOURS PER WEEK?
HOURLY PAY
PREVIOUS EMPLOYER
Your answer
PREVIOUS EMPLOYER - ADDRESS
Your answer
PREVIOUS EMPLOYER - POSITION
Your answer
PREVIOUS EMPLOYER - DATES EMPLOYED
Your answer
SECOND PREVIOUS EMPLOYER
Your answer
SECOND PREVIOUS EMPLOYER - ADDRESS
Your answer
SECOND PREVIOUS EMPLOYER - POSITION
Your answer
SECOND PREVIOUS EMPLOYER - DATES EMPLOYED
Your answer
HIGHEST EDUCATION GRADE COMPLETED
NAME OF LAST SCHOOL ATTENDED
Your answer
ADDRESS OF LAST SCHOOL ATTENDED
Your answer
DATE OF HIGH SCHOOL DIPLOMA
MM
/
DD
/
YYYY
DATE OF GED
MM
/
DD
/
YYYY
ANY COLLEGE OR TRADE SCHOOL?
NAME OF COLLEGE OR TRADE SCHOOL
Your answer
ARE YOU CURRENTLY IN SCHOOL?
NAME OF SCHOOL CURRENTLY ATTENDING
Your answer
DO YOU HAVE AN EDUCATIONAL GOAL?
IF YES, WHAT AREA?
Your answer
ARE YOU AN ACTIVE PERSON?
DO YOU EXERCISE REGULARLY?
WHAT DO YOU LIKE TO DO FOR EXERCISE?
Your answer
WHAT DO YOU DO FOR FUN?
Your answer
DO YOU PREFER BEING ALONE OR WITH FRIENDS?
ARE YOU A MORNING OR NIGHT PERSON?
WHEN DO YOU LIKE TO GO TO BED?
DO YOU KNOW HOW TO COOK?
CAN YOU PREPARE EGGS?
CAN YOU PREPARE HAMBURGERS?
CAN YOU PREPARE BACON?
CAN YOU PREPARE AN ENTIRE MEAL FOR DINNER?
HAVE YOU EVER SHOPPED FOR GROCERIES?
ARE YOU A HEALTHY EATER?
IF NO, WHY NOT?
Your answer
DO YOU HAVE DIETARY RESTRICTIOONS?
DO YOU HAVE A SPECIAL FOOD PREFERENCE?
IF YES, WHAT?
DO YOU KNOW HOW TO DUST, MOP, AND CLEAN AN APARTMENT?
HAVE YOU USED A WASHER OR DRYER?
HAVE YOU LOADED A DISHWASHER?
IN WHICH OF THESE PROGRAMS ARE YOU ENROLLED?
HAVE YOU EVER BEEN ARRESTED OR CONVICTED OF A MISDEMEANOR?
IF YES, WHAT WAS THE NATURE OF THE INCIDENT?
Your answer
IF YOU WERE CONVICTED, WHAT WAS THE DISPOSITION ?
Your answer
HAVE YOU EVER BEEN ARRESTED OR CONVICTED OF A FELONY?
IF YES, WHAT WAS THE NATURE OF THE INCIDENT?
Your answer
IF YOU WERE CONVICTED, WHAT WAS THE DISPOSITION?
Your answer
ARE YOU CURRENTLY ON PROBATION?
WHO IS YOUR PROBATION OFFICER?
Your answer
PROBATION OFFICER PHONE NUMBER
Your answer
WHAT ARE THE CONDITIONS OF YOUR PROBATION?
Your answer
DO YOU HAVE ANY OUTSTANDING WARRANTS, TICKETS, OR PENDING CHARGES AGAINST YOU?
IF YES, EXPLAIN
Your answer
DO YOU HAVE A SCHEDULED COURT APPEARANCE?
IF YES, WHEN?
MM
/
DD
/
YYYY
WHERE?
Your answer
CURRENT MONTHLY INCOME
Your answer
SOURCE OF CURRENT MONTHLY INCOME
Your answer
DO YOU HAVE A BANK ACCOUNT?
DO YOU HAVE A SAVINGS ACCOUNT?
DO YOU HAVE A LOAN?
DO YOU PAY YOUR RENT ON TIME?
DO YOU HAVE ANY CURRENT DEBT?
IF YES, WHAT?
Your answer
IF YES, WITH WHOM?
Your answer
ARE YOU SEXUALLY ACTIVE?
DO YOU HAVE ACCESS TO BIRTH CONTROL?
DO YOU NEED IMMEDIATE HOUSING?
WHAT IS YOUR CURRENT NEED?
Your answer
DO YOU ATTEND CHURCH?
DO YOU HAVE A PERSONAL RELATIONSHIP WITH GOD?
ARE YOU IN COUNSELING?
IF NO, WOULD YOU LIKE TO PARTICIPATE IN COUNSELING?
GENDER
RACE OR ETHNICITY
I CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE AND CORRECT AND UNDERSTAND THAT MY RESIDENT AGREEMENT AND PROGRAM PARTICIPATION MAY BE TERMINATED IF I HAVE MADE ANY FALSE OR INCOMPLETE STATEMENTS IN THIS APPLICATION. I UNDERSTAND THAT THIS IS ONLY PART OF THE APPLICATION PROCESS AND THAT FINAL ACCEPTANCE INTO THE PROGRAM IS CONTINGENT UPON MY SUCCESSFUL COMPLETEION OF AN IN-PERSON INTERVIEW AND FINAL APPROVAL BY THE ANGEL REACH STAFF.
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