Gift Permanent Supportive Housing, Inc.

Application Date:

Time:

Full Name:

Date of Birth:

Social Security #:

Martial Status:

Single
Married
Divorced
Separated
Widower

Gender:

Male
Female
Other

Race:

Afro-American
Caucasian
Hispanic
Other

Phone #:

Place of Birth:

Are you permitted to work in this county?

Yes
No

Are you on probation:

Yes
No

Are you on parole:

Yes
No

Are you physically/medically/mentally able to get a job?

Yes
No

Do you currently have a job?

Yes
No

If no, how do you support yourself?

Family or Friend:

Family
Friend
Other

Source of Income:

SSI
SSDI
Other

How much and do you have a payee?

How much: $ Payee:

Do you receive public Assistant?

Yes
No

Do you receive Food Stamps?

Yes
No

Do you have medical insurance coverage?

Medicaid
Medicare
Other

Medical Diagnosis:

Treated by:

Doctor's phone number:

Doctor's Address:

Last visit:

Current Medications:

Mental Health Diagnosis:

Treated by:

Doctor's phone number:

Doctor's Address:

Last visit:

Current Medications:

Date of last PPD/TB test:

Date of last RPR/Syphilis test:

Do you have a copy of your results:

Yes
No

Do you have your program fee to cover you monthly fee/program services?

Yes
No

Who will pay your program fees and there phone number::

Verified by:

Date:

Referred by (Name, Title):

Date referred:

Recommended for Treatment:

Yes
No

If no, specify reasons:

Date notified the referring agency:

Spoke to:

Pre-screening completed by (Name, Title):

Date and Time: