Applicant’s Name: Last: First: M.I. Address: (Current or Last Numbers: Mobile: Home: Please check if: Alternate or Email: Shelter Temporary Housing Homeless: Yes No Veteran: Yes No Date of Birth (MM/DD/YYYY): Social Security #: Age: Gender: Race: Marital Status: Male Female Transgender Sexual Orientation (Optional): Primary Language: Interpreter Required: U.S. Citizen Yes No Legal Resident Highest of School Completed: Employment Status: Mental Health Diagnoses (please list all you and your doctor have identified): What stands in the way of you completing the things you need to do? Why are you applying for services? What are your What daily activities and skills do you want assistance with or do you think you don’t do well when you are not feeling well. Please check all that apply: Personal hygiene and grooming Exercising Following housing rules Food preparation Keeping room/home clean Taking medications consistently Making healthy food choices Managing budgeting Accessing resources Meeting new people Getting along with friends Getting with family Using supports Getting/using resources Getting and keeping jobs Doing well in school Using transportation Making good decisions Staying safe Other: Other: Somatic/Physical Health Diagnoses or Concerns: Previous History of Drug and Alcohol Use (please include type, when used, in what amount, and how used): Current Drug and Alcohol Use (please include type, when used, in what amount, and how used): Current Medications type, frequency, dose and reason for taking: – Have you been hospitalized for mental health reasons: yes no If yes, list dates, duration and reasons:
Applicant’s Name: Last: First: M.I. Address: (Current or Last Please check if: Shelter Temporary Housing Numbers: Mobile: Home: Alternate or Email: Homeless: Yes No Veteran: Yes No Date of Birth (MM/DD/YYYY): Age: Social Security #: Gender: Male Female Transgender Sexual Orientation (Optional): Race: Marital Status: Primary Language: Interpreter Required: Yes No U.S. Citizen Legal Resident Highest of School Completed: Employment Status: Mental Health Diagnoses (please list all you and your doctor have identified): What stands in the way of you completing the things you need to do? Why are you applying for services? What are your What daily activities and skills do you want assistance with or do you think you don’t do well when you are not feeling well. Please check all that apply: Personal hygiene and grooming Food preparation Making healthy food choices Meeting new people Using supports Doing well in school Staying safe Exercising Keeping room/home clean Managing budgeting Getting along with friends Getting/using resources Using transportation Other: Following housing rules Taking medications consistently Accessing resources Getting with family Getting and keeping jobs Making good decisions Other: Somatic/Physical Health Diagnoses or Concerns: Previous History of Drug and Alcohol Use (please include type, when used, in what amount, and how used): Current Drug and Alcohol Use (please include type, when used, in what amount, and how used): Current Medications – type, frequency, dose and reason for taking: Have you been hospitalized for mental health reasons: yes no If yes, list dates, duration and reasons:
Application-MD-HT-print-version.docx