ALLIANCE HOUSING LLC
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Alliance Housing Intake Application
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Indicates required field
First Name
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Middle Name
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Last Name
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Birth Day
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Email
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Application Date
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Intake Date
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LIVING SITUATION
Where did you stay last night?
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Program or Institution Address:
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Program or Institution Name:
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Program or Institution Phone:
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Length of Stay:
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Reason for Leaving:
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CLIENT PROFILE
Marital Status:
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SIN
MAR
SEP
DIV
WID
SS Card
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Yes
No
SS#
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Birth Cert:
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Yes
No
Race:
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Valid ID:
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Yes
No
ID Type:
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Driver’s License
State ID
ID #:
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ID Expiration Date:
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Veteran:
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Yes
No
Years Served:
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Branch:
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Discharge Type:
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Service-Related Disability:
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Yes
No
Receiving Benefits:
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Yes
No
EMPLOYMENT ASSESSMENT
Most Recent Employer:
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Position:
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Job Duration:
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Job End Reason:
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Skills:
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Resume:
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Yes
No
EDUCATION ASSESSMENT
Choose One
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High School Diploma
GED
Hiset
None
Year Obtained:
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Other School or Training: Y / N
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Yes
No
Describe:
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Degree or Certificate for Other:
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Can you read:
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Yes
No
Can you write:
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Yes
No
Any learning disabilities:
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Yes
No
Describe:
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TWIC:
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Yes
No
FULL TWIC Expiration Date:
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OSHA:
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Yes
No
Other Credentials (Describe):
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LEGAL ASSESSMENT
US Citizen:
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Yes
No
Domestic Violence Victim:
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Yes
No
Domestic Violence Offender:
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Yes
No
Sex Offender:
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Yes
No
Ever Arrested:
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Yes
No
When and Why:
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Ever Incarcerated:
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Yes
No
When and Why:
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How Long:
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Outstanding Warrants:
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Yes
No
Describe:
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Upcoming Court Dates:
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Yes
No
Detail:
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On Parole or Probation:
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Yes
No
Probation Hold:
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Yes
No
Court Ordered Here:
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Yes
No
Probation Officer Name:
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Probation Officer Phone:
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Judge’s Name:
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DEBT ASSESSMENT
Child Support:
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Yes
No
Child Support Amount:
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Child Support Case Number:
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Arrears Owed:
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IRS Debt:
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Yes
No
Amount:
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Government Benefits:
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Yes
No
Type:
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Amount:
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Other Debt:
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FAMILY ASSESSMENT
Spouse:
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Children:
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Discuss any family history of addiction:
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EMERGENCY CONTACT
Emergency Contact Name
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Emergency Contact Relationship:
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Emergency Contact Phone:
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Emergency Contact Address:
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Emergency Contact Name:
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Emergency Contact Relationship:
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Emergency Contact Phone:
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Emergency Contact Address:
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PHYSICAL HEALTH ASSESSMENT
Medical Conditions:
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Ongoing Treatment:
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Yes
No
Treatment Provider:
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Treatment Provider Phone:
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Medications:
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Allergies:
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Medical Coverage:
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Yes
No
Choose:
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Private Insurance
Medicaid
None
Company Name:
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Any Physical Restrictions/Limitations:
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Yes
No
Describe:
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Are you physically capable of participating in this work program:
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Yes
No
Are you disabled:
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Yes
No
What is your disability:
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Are you receiving disability benefits:
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Yes
No
Amount?
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Ever Injured on the job:
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Yes
No
Describe:
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Been or being compensated for work-related injuries:
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Yes
No
Amount:
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Current worker’s comp claim:
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Yes
No
Describe:
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DENTAL HEALTH ASSESSMENT
Dental Problems:
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Last Treated:
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MENTAL HEALTH ASSESSMENT
Mental Health Condition/s:
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Medication/s:
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Mental Disability:
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Yes
No
Receiving Benefits:
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Yes
No
Amount:
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Counseling/Therapy:
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Yes
No
Where:
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Who:
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Contact:
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Ever lived in an institution:
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Yes
No
Name:
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Dates:
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Do you have an addiction:
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Yes
No
How long?
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Describe:
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Problems Caused by this addiction:
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REFERRAL INFORMATION
Referred by:
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Referral Contact:
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ACKNOWLEDGEMENT, VERIFICATION & AUTHORIZATION FORM
I (type Name Below)
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, declare that all of the information on this application is true and correct. I realize that completion of this application does not guarantee my acceptance into The Orchard House program.
I, have been made aware of the policies and procedures on pages 2-17 of the handbook of The Orchard House program and agree to them.
I, understand and agree that I will be charged $ per day to reside and participate in The Orchard House program.
I, understand that all equipment and clothing; such as, but not limited to shirts, uniforms, work boots, hard hats, gloves, safety glasses, towels, bedding, etc., given to me by TOH/Alliance is the property of TOH/Alliance and that I am being allowed to use these items on a temporary basis. I agree to use the items as intended and with care. If the property is damaged, lost or not needed I must report this to my immediate supervisor and I will be held responsible for repair, replacement or return of the said items and any expenses will be covered by payroll deduction. I understand and agree that failure to repair, replace, return or reimburse for said items by me could be considered theft and could lead to charges.
I, authorize The Orchard House and/or Alliance to record and edit my likeness, image, voice, interview and performance. I agree that the above entities may use and authorize the use of any part of this documentation for, but not limited to, exhibition, publication, educational and website purposes. Additionally, I waive any right to royalties or other compensation arising from or related to the use of my image or recording. I also understand that this material may be used in diverse settings within an unrestricted geographic area. I hereby release any and all claims against The Orchard House and/or Alliance utilizing this material for above purposes.
Participant Signature
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Date
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Submit
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