Cedars HOPE

Event Calendar

Services Application

Personal Information
Name
Phone Number
Current Residence (shelter, hospital, street, etc.)
How long have you been there?
List your last address
What is the best way to contact you?
Date of birth
Where were you born?
Age
Social Security Number
Marital Status
Number of Children and their ages
Do you have custody of any minor children?	Yes No
Application Assistance
Did someone help you with this application?	Yes No
Name of person helping you with this application
Phone number of person helping with this application
Address of person helping with this application
May we contact this person?	Yes No
Emergency Contact Info
Name
Relationship
Address
Phone Number
Last contact with this person
Other Personal Information
Any other personal information you would like us to know about you.
Medical Information
List all current health problems
Do you have any physical limitations? If yes, please explain.
Do you have any allergies? If yes, please explain.
Approximate dates of your last:	Eye exam:
	Dental exam:
	Hearing exam:
	Physical exam:
	Mammogram:
Family Doctor's name
Family Doctor's phone
Family Dentist's name
Family Dentist's phone
Family Eye Doctor's name
Family Eye Doctor's phone
OB-GYN's name
OB-GYN's phone
List all current medications
Are you compliant with taking your medications? If no, please explain.
Do you currently administer you own medications? if no, please explain.
Do you use birth control? If yes, which type?
Do you have seizure disorder? If yes, explain frequency and type.
Do you have problems with bladder control? If yes, please explain.
Do you have diabetes? If yes, explain how it is controlled (meds, insulin, diet/exercise)
If you take insulin for control your diabetes, can you give the insulin to yourself independently? If no, please explain.
Psychiatric Information
Current Diagnosis
Current Psychiatric symptoms
Past Psychiatric symptoms
List all current psychiatric medications (name, dose, frequency, etc.)
Are you compliant with taking your psychiatric medications? If no, please explain.
Any past or current drug and alcohol use? Explain when you last used substances.
Have you ever threatened to harm yourself or others or actually harmed yourself or others? If yes, please explain.
List all psychiatric hospitalizations you have had (start with the most recent visit).
Psychiatrist's name
Psychiatrist's phone
Therapist's name
Therapist's phone
Case Manager's name
Case Manager's phone
Do you attend any treatment programs or groups provided by a mental health facility? If yes, please explain.
We will need documentation (on company letterhead) of all psychiatric services that you currently receive. Please send the documentation after submitting this application.
Legal Information
Do you have a court appointed financial or medical guardian? If yes, please explain.
We will need copies of your court documents if you have a legal guardian.
Do you have power of attorney? If yes, please explain.
We will need documentation of these forms if applicable.
Benefit Information
Resources
SSI
SSDI
Medicare
Medicare D
Medicaid	Amount:
Food Stamps
Spenddown
Other Income
Other Insurance
Employment
If you receive benefits from Social Security, do you manage your own finances or do you you have a representative payee (provide name and phone # of current payee if applicable).
Adult Daily Living Skills
Mark the following that you can do independently without assistance from others.
Cooking Sweeping and mopping the floors Dishes Taking out the trash
Laundry Dusting Showering Light yard work Riding the bus / arrange cab
Other Information
Have you ever been arrested? If yes, please explain.
Have you ever been evicted due to violent behaviors or drug / alcohol? If yes, please explain.
Other information you think we should know about or want to share.
Criteria for Homelessness
We must have proof or documentation of homelessness. A person must be homeless in order to receive assistance under the Department of Housing and Urban Development's homeless programs. A person is considered homeless only when he or she resides in one of the following categories as described below. Please, check the factors that apply to you.
Person living on street — we need a signed and dated general certification from an outreach worker verifying the services are going to homeless persons, and indicates where the person resides.
Person coming from living on the street (and into a place meant for human habitation) — we need written information from a third party regarding the participant's whereabouts, and then sign and date the statement.
Person coming from an emergency shelter for homeless persons — we need a written referral from the agency.
Person coming from transitional housing for homeless persons — we need written verifications to include program residency and homeless status prior to program entry.
Person being evicted from a private dwelling — we need documentation of income, efforts to obtain housing, why participant would be on the street, and either documentation of formal eviction proceedings or statement from family evicting participant.
Person from a short-term stay in an institution who previously resided on the street or in an emergency shelter — we need written verification from the institution's staff that the participant has been residing in the institution for less than 31 days, and information on the previous living situation.
Person being discharged from a longer stay in an institution — we need written verification from the institution of discharge within one week of receiving homeless assistance and documentation of income, efforts to obtain housing, and why the person would be homeless without assistance.
Person fleeing domestic violence — we need a written, signed, and dated verification from the participant.
When could you begin residing at Cedars HOPE?
Please, submit all of your documentation with this completed application. Thank you I certify that the information I have provided is accurate to the best of my knowledge. I understand that providing false information can result in disqualification from the application process or dismissal from Cedars HOPE.
Applicant's signature (Please type)
Date

SEPTEMBER 2010
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