Union Rescue Mission
Los Angeles Skid row
Union Rescue Mission
Los Angeles Skid row
Hope Gardens Intake Application
Application to be completed by Approved Referring Agency only
Step
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Transitional Housing Program for Women and Children Agency Referral
Please complete the Hope Gardens intake application below. The following form is required for every applicant for the Union Rescue Mission Hope Gardens Program. In order for URM to expedite the process of reviewing and approving your application, please complete the form thoroughly.
Confirm below
(Required)
This is to confirm that this family is currently experiencing homelessness.
Date of Referral
(Required)
MM slash DD slash YYYY
Referring Agency Name
(Required)
Address
(Required)
Email
(Required)
Contact Person
(Required)
Title
(Required)
Phone
(Required)
Demographic Information
Please enter the applicant information accurately.
Applicant First and Last Name
(Required)
First
Last
Age
(Required)
DOB
(Required)
MM slash DD slash YYYY
Applicant cell phone number
(Required)
Applicant email address
(Required)
Soc. Sec. #
(Required)
Marital Status
(Required)
Single
Married
Divorced
Widowed
Marital Status Contact Information (as needed
First
Last
DOB
MM slash DD slash YYYY
City of Residence
U.S. Citizen
(Required)
Yes
No
Birth Certificates
(Required)
Yes
No
Social Security Cards
(Required)
Yes
No
If no, please explain
Valid Drivers License
(Required)
Yes
No
If yes, please provide DL Number
Vehicle Information
Enter the applicant vehicle information.
Year
Make
Model
License Plate Number
Valid Insurance
Yes
No
Registration
Yes
No
Ethnicity Information
Race & Ethnicity:
(Required)
Native American or Alaskan Native
Asian
Native Hawaiian
Pacific Islander
Black/African-American
Caucasian
Latino
Mixed
Other
If other
Primary language spoken
(Required)
Other language(s) spoken
Religious Background
(Required)
In Case of Emergency
Full Name
(Required)
First
Last
Phone Number
(Required)
Relationship
(Required)
Full Name
First
Last
Phone Number
Relationship
Child (ren) Applicant has custody of
Please enter below each child of the applicant.
Child 1:
Name
Gender
Yes
No
Age
DOB
MM slash DD slash YYYY
In School
Yes
No
Child Care
Yes
No
Birth Cerificate
Yes
No
Social Security Card
Yes
No
Father's name
DOB
MM slash DD slash YYYY
City of Residence
Involvement
Yes
No
Child 2:
Name
Gender
Yes
No
Age
DOB
MM slash DD slash YYYY
In School
Yes
No
Child Care
Yes
No
Birth Cerificate
Yes
No
Social Security Card
Yes
No
Father's name
DOB
MM slash DD slash YYYY
City of Residence
Involvement
Yes
No
Child 3:
Name
Gender
Yes
No
Age
DOB
MM slash DD slash YYYY
In School
Yes
No
Child Care
Yes
No
Birth Cerificate
Yes
No
Social Security Card
Yes
No
Father's name
DOB
MM slash DD slash YYYY
City of Residence
Involvement
Yes
No
Child 4:
Name
Gender
Yes
No
Age
DOB
MM slash DD slash YYYY
In School
Yes
No
Child Care
Yes
No
Birth Cerificate
Yes
No
Social Security Card
Yes
No
Father's name
DOB
MM slash DD slash YYYY
City of Residence
Involvement
Yes
No
Child 5:
Name
Gender
Yes
No
Age
DOB
MM slash DD slash YYYY
In School
Yes
No
Child Care
Yes
No
Birth Cerificate
Yes
No
Social Security Card
Yes
No
Father's name
DOB
MM slash DD slash YYYY
City of Residence
Involvement
Yes
No
Child 6:
Name
Gender
Yes
No
Age
DOB
MM slash DD slash YYYY
In School
Yes
No
Child Care
Yes
No
Birth Cerificate
Yes
No
Social Security Card
Yes
No
Father's name
DOB
MM slash DD slash YYYY
City of Residence
Involvement
Yes
No
Is mother currently pregnant
(Required)
Yes
No
If yes, what is her due date?
MM slash DD slash YYYY
Father's name
(Required)
DOB
(Required)
MM slash DD slash YYYY
City of Residence
(Required)
Involvement
(Required)
Yes
No
List any children not in applicant’s custody (Include age and gender of children)
Do any of the applicant’s child(ren) have have any the following:
Behavioral problems
Emotional/Anger issues
Trouble at School
IEP
Hearing/Sight impairments
Developmental Delays
Mental Health
Autism
Medical Conditions
Physical disabilities
Other
If other, explain here:
Department of Children and Family Services (DCFS) History
Does applicant have a DCFS referral or case ?
(Required)
Yes
No
Date case opened:
(Required)
MM slash DD slash YYYY
Date case closed (if applicable)
(Required)
MM slash DD slash YYYY
Who made referral?
(Required)
Reason for referral:
(Required)
DCFS Social Worker Name:
(Required)
Social Workers phone number:
(Required)
Email
(Required)
Is applicant required to complete?
Parenting
Domestic Violence
Substance Abuse
Anger Management
Psychotherapy
Other
If other, explain:
Has applicant completed the court mandated classes? Explain:
Does the applicant have monitor/unmonitored visitation with child/ren? Explain:
(Required)
Is reunification anticipated?
(Required)
Yes
No
If no, please explain:
History of Homelessness
How did the applicant’s become homeless?
(Required)
How long has applicant currently been experiencing homelessness?
(Required)
Address of current residence:
(Required)
Phone number of current residence:
(Required)
Time remaining at current residence:
(Required)
Can stay be extended?
(Required)
Yes
No
What services has the applicant used in the past?
(Required)
Emergency Shelters
Domestic violence shelter
Permanent supportive housing
Hotel/motel voucher
Transitional housing
Section 8 Housing
Other
If other:
Is applicant currently using homeless vouchers through LAHSA, DPSS, FEMA or other programs?
(Required)
Yes
No
If yes, how many days have been used?
Is there a possibility of an extension?
(Required)
Yes
No
Has applicant used homeless vouchers in the past?
(Required)
Yes
No
If yes, please explain:
Date(s) of other times applicant has experienced homelessness:
Has applicant previously used rental assistance programs to move into permanent housing?
(Required)
Yes
No
Is the applicant currently on the waitlist for Section 8/ Public housing?
(Required)
Yes
No
Legal History
Has applicant ever been arrested?
(Required)
Yes
No
If yes, please explain:
Has applicant ever been convicted of misdemeanor/felony?
(Required)
Yes
No
If yes, please explain
Has the applicant been to jail or prison?
(Required)
Yes
No
If yes, please explain
Is applicant currently on probation or parole?
(Required)
Yes
No
Probation Office Name:
P.O. phone number:
Email
Does applicant have any outstanding tickets or warrents?
(Required)
Yes
No
If yes, please explain
Substance Abuse History
PERIOD OF CURRENT SOBRIETY MUST BE GREATER THAN 6 MONTHS
Does applicant have a history of drug or alcohol abuse?
(Required)
Yes
No
Which of the following substances has the applicant used? ( check the following that applies to applicant)
LSD
Ecstasy
Benzodiazepine
PC
Alcohol
Inhalant
Methamphetamine
Steroids
Opioids
Marijuana/Spice
Cocaine/Crack Cocaine
Other
If there is a history, what is the date of the applicant’s last drug test?
(Required)
Yes
No
Test Results
Positive
Negative
If positive, please list substances detected:
Has applicant been to a drug/alcohol treatment program:
(Required)
Yes
No
What was name of the treatment facility and Substance Abuse Counselor:
Did the applicant complete the drug/ alcohol treatment program?
(Required)
Yes
No
Completion date:
MM slash DD slash YYYY
How long has the applicant been sober?
(Required)
Does the applicant have a sponsor or support group?
(Required)
Yes
No
Please provide sponsor information if applicable:
Phone Number:
What is applicant relapse triggers:`
Does applicant attend weekly AA or NA meetings?
(Required)
Yes
No
Is the applicant court mandant to attend AA or NA meetings?
(Required)
Yes
No
Mental Health History
Please provide all information if applicable.
Does applicant and/or child (ren) have a history of mental illness?
(Required)
Yes
No
If yes, please explain:
Does applicant and/or child (ren) take psychotropic medication?
(Required)
Yes
No
If yes, please explain:
Has applicant ever been voluntarily/involuntarily hospitalized for a psychiatric diagnosis?
(Required)
Yes
No
If yes, please explain:
Psychotherapist Name:
Phone Number:
Psychiatrist Name:
Phone Number:
Medical History
Does applicant and/or child (ren) have a medical diagnosis?
(Required)
Yes
No
If yes, please explain:
Does applicant and/or child (ren) take any prescribed medication?
(Required)
Yes
No
If yes, please explain:
Is applicant enrolled in MediCal?
(Required)
Yes
No
Other Health Plan:
Date of applicant’s most recent physical exam:
(Required)
MM slash DD slash YYYY
Dental exam:
(Required)
MM slash DD slash YYYY
Date of applicant’s most recent tuberculosis skin test:
(Required)
MM slash DD slash YYYY
Test Results:
(Required)
Negative
Positive
If positive, was there a chest x-ray taken?
Yes
No
If yes, what were results?
Has applicant ever been hospitalized for a medical diagnosis?
(Required)
Yes
No
If yes, please explain:
Does the applicant and/or children have allergies to the following:
Aspirin, ibuprofen, acetaminophe
Penicilli
Local anesthet
Food: (milk, nuts, whea
Fluoride
Latex
Metals (nickel, gold, silver)
Other
Primary Care Physician Name:
Address:
Phone Number
Domestic Violence History
Has applicant ever been a victim of domestic violence?
(Required)
Yes
No
Please describe to types of Domestic Violence the applicant has experienced:
Please give date(s) and location(s) of domestic violence incident(s):
Did applicant file a police report for the above domestic violence incidents?
(Required)
Yes
No
Does applicant have contact with perpetrator of domestic violence?
Yes
No
If yes, please explain:
What is the current location of the perpetrator of the domestic violence?
How long was the applicant with the perpetrator?
Length of current period away from perpetrator of domestic violence:
Has the perpetrator been arrested due to the domestic violence?
Yes
No
Does applicant have a protective order against the perpetrator?
Yes
No
Does applicant have to testify in court against the perpetrator?
Yes
No
Has the perpetrator been sentence in the domestic violence case?
Yes
No
Is the applicant receiving VOC assistance due to the domestic violence?
Yes
No
Has applicant received any domestic violence counseling?
Yes
No
If yes, please provide information:
Does applicant have an open DCFS case due to the domestic violence?
(Required)
Yes
No
Did the applicant child(ren) witness the domestic violence incident(s)?
Yes
No
Were the children ever physical harmed by the perpetrator?
Yes
No
If yes please explain:
Has the applicant been a perpetrator of domestic violence?
Yes
No
If yes please explain:
Applicant Income History
DPSS/Cal Works Caseworker name:
(Required)
Phone Number
(Required)
DPSS/Cal Works Case Number:
(Required)
DPSS/Cal Works File Number:
(Required)
DPSS/Cal Works amount:
(Required)
DPSS/Cal Works Frequency
(Required)
daily
weekly
2x/month
1x/month
Job income:
(Required)
Job income Frequency
(Required)
daily
weekly
2x/month
1x/month
Unemployment income:
Unemployment income Frequency
daily
weekly
2x/month
1x/month
SSI/SSDI income:
SSI/SSDI income Frequency
daily
weekly
2x/month
1x/month
Child Support income:
Child Support income Frequency
daily
weekly
2x/month
1x/month
Alimony income:
Alimony income Frequency
daily
weekly
2x/month
1x/month
Food Stamps income:
(Required)
Food Stamps income Frequency
(Required)
2x/month
1x/month
Date of issuance:
MM slash DD slash YYYY
Total monthly income:
(Required)
How much money does applicant have in savings?
(Required)
Does the applicant currently paying any of the following expenses:
Storage: $
Student Loan: $
Car Payment: $
Traffic Tickets: $
Insurance: $
Other: $
Owed To:
Please list all known delinquencies expected to appear on applicant’s credit report:
Amount Owed:
Owed To:
Date (s) Incurred:
Educational/Vocational History
Please complete accurately.
What is the highest grade that the applicant completed?
(Required)
K-5th
6th-8th
9-12th
Trade school
Some college
AA
BA
Masters
Please list all degrees and certificates awarded to applicant:
What is the applicant education/Vocatinal goal:
Employment History
Applicant is currently:
Employed
Unemployed
Retired
Disabled
Never Employed
Please list applicants last three places of employment:
Include the employers name, your job title and how many years you were employed.
Have you ever been terminated or release from a position/employment?
Yes
No
If yes, explain why you were terminated from employment:
Have you ever had an injury/illness that may have been caused by your previous employer?
Yes
No
What are your employment barriers:
What is your profession goals:
Agency Narrative
Please describe the applicant’s current strengths:
Please describe the applicant’s current challenges:
How would the applicant benefit from the services this program provides?
What goals would the applicant like to accomplish while involved in this program?
What is important for us to know about the applicant?
What services has your agency provided the applicant?
Did the applicant make use of all services available through your agency?
I understand that the Union Rescue Mission’s Hope Gardens Family Center program staff may contact persons or agencies that I have provided information about in this application, and will communicate with other Union Rescue Mission employees and collaborative partners as needed to accomplish goals set forth in my Individualized Service Plan. I hereby state that all the information submitted is accurate to the best of my knowledge.
Referring Agency Signature
Date
MM slash DD slash YYYY
Applicant Signature:
Date
MM slash DD slash YYYY
