Families Together Application Form

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"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Name*

First Last

Maiden Name

Current Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number*

Country Phone Number

Email*

Place of Birth*

City, State

Date of Birth*

Social Security Number*

Language of Choice*

Specify Language of Choice:*

Religious Preference*

Specify Religious Preference:*

Ethnicity*

Specify Ethnicity:*

Educational Background*

Currently Employed?*

Yes

Occupation*

Place of Employment*

Hours Per Week*

Please enter a number greater than or equal to 0.

Monthly Income*

Length of Employment*

Employers Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number*

Country Phone Number

Are You Pregnant?*

Yes

Marital Status*

Are you being stalked?*

Yes

Describe the relationship with your Spouse/Partner:*

Is your Spouse/Partner the parent of your children?*

Yes

Are visitations allowed between Spouse/Partner of your children?*

Yes

How many previous marriages have you had?*

Please enter a number greater than or equal to 0.

Previous Marriage*

Marriage Date*

Divorce Date*

Previous Marriage*

Marriage Date*

Divorce Date*

Previous Marriage*

Marriage Date*

Divorce Date*

Spouse/Partner Information

Name*

First Last

Maiden Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Country Phone Number

Place of Birth*

City, State

Date of Birth*

Language of Choice*

Specify Language of Choice:*

Religious Preference*

Specify Religious Preference:*

Ethnicity*

Specify Ethnicity:*

Educational Background*

Currently Employed?*

Yes

Occupation*

Place of Employment*

Hours Per Week*

Please enter a number greater than or equal to 0.

Monthly Income*

Length of Employment*

Employers Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone Number*

Country Phone Number

Please List Previous Addresses

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What led you to seeking services from Families Together?*

In the last year, did you live in a residence that was listed in your name?*

Yes

Please describe your current homeless situation & how long you have been homeless.*

Please describe your educational background and job training history.*

Please describe work history

Employer

Phone

Country Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Length of time at job

Employer

Phone

Country Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Length of time at job

Employer

Phone

Country Phone Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Length of time at job

Please describe your current insurance situation for you and your children*

Please describe your current transportation situation/needs*

Please check all sources of income*

Employment Pay*

SSI Benefits*

Food Stamps*

TANF*

Children's SSI*

WIC Assistance*

Grants*

Loans*

Financial Aid*

Other Source of Income*

Have you applied or been approved for Crime Victim's Compensation?*

Yes

Please Explain*

Have you experienced evictions or barriers to housing in the past?*

Yes

Please list and explain past evictions or barriers to housing*

Date

Eviction/Barrier

Has this been paid?

Do you have any unpaid debts?*

Yes

Please list any unpaid debts you currently have*

Debt

Amount Owed

Have you ever been diagnosed with any mental health disorders?*

Yes

Please Explain*

Date

Diagnosis

Has there been any recent hospitalizations for psychological issues in the last 6-months to a year?*

Any recent suicidal or self-harming behaviors over the last year?*

Are you currently taking any medications?*

Yes

Please list any medications you are taking and what it is prescribed for*

Medication

Reason

Are you currently receiving medication management services by a provider for any type of mental health diagnoses?*

Yes

Are you currently receiving counseling?*

Yes

Are you open to receiving counseling?*

Yes

Maybe

Please describe your current health needs*

Criminal History

Do you have any misdemeanor or felony arrests?*

Yes

Please list any misdemeanor or felony arrests along with dates and outcomes*

Arrest

Date

Outcome

Are you on probation or parole?*

Yes

Please describe the conditions of your probation or parole*

Substance Abuse History

Do you currently consume drugs or alcohol?*

Yes

Please describe your current drug or alcohol consumption*

What is the date of last use?*

How often do you use?*

Have you ever received any substance abuse services?*

Yes

Have you ever been diagnosed with substance abuse disorders?*

Yes

Please Explain*

Are you addicted to drugs or alcohol?*

Yes

Please Specify Substance(s)*

Please describe your relationship with your children*

What are your children's thoughts on joining the Families Together program?*

Please list in detail the goals you will establish in the following areas

Housing*

Employment*

Transportation*

Day-Care/School Enrollment*

Public Benefits*

Insurance*

Any other agencies having contact with the family?*

Ex: Therapists, Psychiatrists, Hospital, MHMR, Juvenile Department, DHS, etc...

Yes

List Agencies*

Type of Service/Agency

Date Started

City

Doctor/Counselor/Caseworker

Phone

How many children do you have?*

Please enter a number from 1 to 3.

Child Information #1

Name*

First Last

Age*

Sex*

Birth Date*

Grade*

Ethnicity*

Does the child reside with you?*

Yes

Child Information #2

Name*

First Last

Age*

Sex*

Birth Date*

Grade*

Ethnicity*

Does the child reside with you?*

Yes

Child Information #3

Name*

First Last

Age*

Sex*

Birth Date*

Grade*

Ethnicity*

Does the child reside with you?*

Yes

List Legal Guardian(s) for Children

List Legal Guardian(s) for Children*

Child

Guardian

Are Any Relatives Involved?*

Yes

Relative #1

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship?*

Phone*

Country Phone Number

OK to Contact?*

Yes

Relative #2

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship?

Phone

Country Phone Number

OK to Contact?

Yes

School Information for Child #1

Name of School*

Grade*

Phone*

Country Phone Number

Name of Principal*

Name of Teacher*

Is child enrolled in special education?*

Yes

List type of services received*

Name of school counselor*

OK to contact?*

Yes

Does your child have a 504 plan?*

Yes

Please list extra-curricular school activities your child is involved in or special honors received by your child*

Medical and Psychiatric History for Child #1

Does your child have a current mental health diagnosis?*

Yes

Diagnosis Date*

Date of Diagnosis

Diagnosis

Is your child currently taking regular medications?*

Yes

List Medications*

Name of Medication

What is it prescribed for?

Does your child have current shot records?*

Yes

What emergency health needs does your child have?*

(Ex: Asthma, Allergies, Diabetes, Seizures, etc...)

What type of medical care is your child currently receiving?*

Child's medical history*

(include immunizations, operations, and childhood illness)

Does your child have any juvenile convictions?*

Yes

Please Explain*

Describe your child's behavior*

How do they interact with other children?*

Any self-harming behaviors?*

Any history of drug or alcohol use?*

Trauma history?*

School Information for Child #2

Name of School*

Grade*

Phone*

Country Phone Number

Name of Principal*

Name of Teacher*

Is child enrolled in special education?*

Yes

List type of services received*

Name of school counselor*

OK to contact?*

Yes

Does your child have a 504 plan?*

Yes

Please list extra-curricular school activities your child is involved in or special honors received by your child*

Medical and Psychiatric History for Child #2

Does your child have a current mental health diagnosis?*

Yes

Diagnosis Date*

Date of Diagnosis

Diagnosis

Is your child currently taking regular medications?*

Yes

List Medications*

Name of Medication

What is it prescribed for?

Does your child have current shot records?*

Yes

What emergency health needs does your child have?*

(Ex: Asthma, Allergies, Diabetes, Seizures, etc...)

What type of medical care is your child currently receiving?*

Child's medical history*

(include immunizations, operations, and childhood illness)

Does your child have any juvenile convictions?*

Yes

Please Explain*

Describe your child's behavior*

How do they interact with other children?*

Any self-harming behaviors?*

Any history of drug or alcohol use?*

Trauma history?*

School Information for Child #3

Name of School*

Grade*

Phone*

Country Phone Number

Name of Principal*

Name of Teacher*

Is child enrolled in special education?*

Yes

List type of services received*

Name of school counselor*

OK to contact?*

Yes

Does your child have a 504 plan?*

Yes

Please list extra-curricular school activities your child is involved in or special honors received by your child*

Medical and Psychiatric History for Child #3

Does your child have a current mental health diagnosis?*

Yes

Diagnosis Date*

Date of Diagnosis

Diagnosis

Is your child currently taking regular medications?*

Yes

List Medications*

Name of Medication

What is it prescribed for?

Does your child have current shot records?*

Yes

What emergency health needs does your child have?*

(Ex: Asthma, Allergies, Diabetes, Seizures, etc...)

What type of medical care is your child currently receiving?*

Child's medical history*

(include immunizations, operations, and childhood illness)

Does your child have any juvenile convictions?*

Yes

Please Explain*

Describe your child's behavior*

How do they interact with other children?*

Any self-harming behaviors?*

Any history of drug or alcohol use?*

Trauma history?*

Consent and Acknowledgement

Signature*

Date*

Get Immediate Help

Call 817.335.HOPE (4673)

OR

1.888.296.8099

Answered 24 hours a day

Not an emergency services phone number. Call 911 for medical emergencies.

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Families Together Application Form

Privacy Notice

Spouse/Partner Information

Please List Previous Addresses

Please describe work history

Criminal History

Substance Abuse History

Please list in detail the goals you will establish in the following areas

Child Information #1

Child Information #2

Child Information #3

List Legal Guardian(s) for Children

Relative #1

Relative #2

School Information for Child #1

Medical and Psychiatric History for Child #1

School Information for Child #2

Medical and Psychiatric History for Child #2

School Information for Child #3

Medical and Psychiatric History for Child #3

Consent and Acknowledgement

Get Immediate Help

OR

Answered 24 hours a day

YOUTH EMERGENCY SHELTER

TURNING POINT

SUICIDE PREVENTION

REPORT CHILD ABUSE

Security Alert

Under $25,000