subject_line
AMAAD General Housing Application
GENERAL HOUSING APPLICATION
Interim Housing Referral Form
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Yes
No
Participant Information
First Name
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Last Name
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Do you have a valid ID?
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Yes
No
Participant Current Address/Location
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Phone Number
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Email Address
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Date of Birth
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+
What is your gender?
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Male
Female
Transgender (M to F)
Transgender (F to M)
Other
Other
Pronoun Preference
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Primary Language Spoken
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Limited English proficiency requiring translation services?
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Did the participant exit an institution (Jail/Prison, Hospital, Foster Care, Detention Center, Residential Care Facility or Substance Use Treatment Facility) within the last 90 days?
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Yes
No
If yes, please specify discharge date:
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Is the participant conserved or does the participant have a conservatorship hearing pending?
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Yes
No
LPS
Probate
If yes, type of conservatorship:
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Is the participant on:
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Probation
AB 109 Probation
Parole
Non-Revocable Parole (Does not report to Parole Agent)
N/A
Ethnicity
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Hispanic
Not Hispanic
Race
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White
Black/ African American
Mexican American
American Indian/ Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Other
Other
Do you have the following identifying documents (Check All That Apply)
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Valid ID/DL
Birth Certificate
Proof of Income/Verification of Benefits
Disability Certification
Permanent Resident ID
DD214(For Veterans)
SS Card
TB Clearance (Last 12 Months)
Covid Test Results (Last 72 Hours)
Certification of Homelessness
In Progress To Obtain Documents
In Progress To Obtain Documents
Would you be comfortable living in a home where LGBTQ+ individuals are openly celebrated?
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Yes
No
Don't Know
Where did you spend most of your nights, in the past 30 days?
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Independent Living/Housing
Family/Relatives Home
Friend's Home
Foster Care
Permanent Supportive Housing
Bridge Housing
Transitional Housing
Rapid Re-Housing
Sober Living Home
Homeless - Sheltered (e.g. couch surfing, hotel or motel, crisis housing)
Homeless - Unsheltered (e.g. on the street or in a place not meant for habitation)
Incarcerated
Other (specify)
Current Address ( if no address put homeless )
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City
State
Phone Number
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Emergency Contact
First Name
Last Name
Address
City
City
Phone Number
Presenting Issue(s). Select all that apply to the participant.
Medical, specify?
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Yes
No
Primary Issue?
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Mental Health, specify?
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Do you currently pay rent?
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Yes
No
Have you ever been served a late rent notice?
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Yes
No
Have you ever been evicted?
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Yes
No
Do you have any outstanding utility bills?
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Yes
No
Have you ever applied for government-sponsored housing? (i.e. Section 8, Shelter Plus Care, SRO)
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Yes
No
Do you owe any debt to a public agency (i.e. Housing Authority, Child Support, etc.)
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Yes
No
Have you ever committed fraud while receiving housing assistance?
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Yes
No
Have you had any problems with previous landlords?
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Yes
No
How much rent do you pay per month?
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ment
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Choice A
Choice B
Have you ever lived in a transitional living facility before?
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Yes
No
What transitional living facility have you lived in before?
Are you a student?
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Yes
No
Grade of Education Last Completed
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6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
1 year of college
2 years of college
3 years of college
4 or more years of college
What is your income source?
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Work/Employment
Unemployment
Disability/SSI
GR Housing Subsidy
Family/Friends
None
Other
Other
Where are you employed? ( if unemployed write "n/a" )
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Total Monthly Income ( if no income write "0" )
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In the last 30 days have you used any substances?
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Yes
No
If yes, what drugs have you used?
Are you currently or planning on attending any outpatient or mental health therapy?
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Yes
No
Are you currently taking any medications?
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Yes
No
If yes, what medications are you taking?
Do you currently have a case manager at any agency?
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Yes
No
Agency Name
Case Manager Name
Case Manager Telephone Number
Name of a Personal or Professional Reference
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Telephone Number of Reference
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Have you ever been convicted of a felony?
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Yes
No
Describe conviction charges
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Are you currently on probation or parole?
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Yes
No
Over the past 2 weeks, how often have you been bothered by any of following problems?
Little interest or pleasure in doing things.
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Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless.
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Not at all
Several days
More than half the days
Nearly every day
Trouble falling asleep or staying asleep, or sleeping too much.
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Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy.
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Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating.
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Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself -- or that you are a failure or have let yourself or your family down.
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Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television.
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Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have noticed. Or the opposite -- being so fidgety or restless that you been moving around a lot more than usual.
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Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead, or of hurting yourself in some way.
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Not at all
Several days
More than half the days
Nearly every day
If you are experiencing any of the above problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
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Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
For Office Use Only
Motivational Interview Conducted by:
Housing Program Assigned To:
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House of Resiliency
Project imPACT
Resilient Solutions
Reclaiming Innocence
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