ROSIE Intake Form

ROSIE Intake Form Program Entry Date ______/_____/20_____ Referred by:______SSN: ______/______/______Last Name: ______First:______Middle Name:______Current Address:______City: ______State:____Zip:______# Weeks/Months at temp Address: ______is applicant pregnant  yes  no #Months pregnant ______Date of Birth: ______Sex:  Male  Female **Disabled:  yes  no Domestic Violence  yes  no Phone #:______**List medical Problem(s) from pg. 2: ______Marital Status: Education: Race:  Single  0-8 years  African American/Black  Married  9-12(non HS grad) Ethnicity:  Caucasian  Separated  HS Grad/GED  Native Hawaiian/ Pacific Islndr.  Widowed  12+  Hispanic/ Asian  Asian  Divorced  College Grad Latino Origin  American Indian/AK Native  Junior College  African American & White  College (non grad)  American Indian/AK/White  Voc/Tech (completed)  Asian & White  Graduate Degree  American Indian/AK/Black # of Persons in the household (include Head of Household)______ Other Multi Racial Last Permanent Address: (Last Place resided for 90 days or more) Street Address: ______City:______State: _____ Zip:______Last Perm. Phone:______Food Stamps:  yes  no $_____ Where did you stay last night? # weeks/months at last permanent address: ______ On the street Monthly Income & Amounts: Family Type:  Emergency Shelter Child Support:  Single Female  Transitional Housing TANF:  Single Male  Psychiatric Facility Employment FT:  Female w/ children  Substance Abuse/Detox Facility Employment PT:  Male w/ children  Hospital (non-psychiatric) Pension:  Couple no children  jail/prison/juvenile facility Veterans Ben:  Couple w/children  Domestic Violence Situation SSA:  Extended family  Living w/relatives/friends SSDI:  Apartment/house you rent SSI: Insurance Type:  Apartment/house you own Unemployment:  Medicare  Staying/living with family Other:  Medicaid  Staying/living with friend  Private  Motel NOT paid by ES shelter voucher Total: $  None  Foster care/group home  VA Medical  Permanent Supportive Housing Total Monthly Family Income: $  Place not meant for habitation (e.g., car/bus/train/subway/outside) Veteran:  yes  no  don’t know  refused  Other______

Housing Status & Cost of Housing With regard to where you stayed last night, how long  Homeless- have you stayed/resided there? Homeless length______1 week or less  Rent $______ more than 1 week, less than 1 month  Own $______ 1-3 months *List the number of homeless shelters you have  4-6 months stayed at in the prior 6 months?______ 7-12 months *List the number of homeless episodes you have  1-2 years experienced within the last 3 years ______ 2-4 years  4 years or more Date:______Reason for Homelessness/Emergency Assistance: CHOOSE ONE!  Stranded/Transient  Insufficient Income  Fire/disaster  Drug/Alcohol Problem  Eviction  High Risk Neighborhood  Loss of Public Assistance  Alcohol Abuse  Release from corrections facility  Medical Condition  Drug Abuse  Mismanagement of income  Substance Abuse  Domestic Violence  Release from Mental Health Facility  Condemnation  Other—Specify______Medical Problems to choose from: Drug Problem Alcohol Problem Physical Health Mental Health ADHD Physical Handicap HIV/AIDS infected Domestic Violence Dual Diag. SA MI Other-Specify: Dual Diag. MI DD Dual Diag. AA MI Develop Disability Learning Disability ______Family Member Information Relationship to Applicant:______SSN:______-_____-______Education: ______Last Name:______First Name:______Middle Name:______Last Perm. Address for Adult, if different than HoH ______City______State ______Zip______Veteran:  yes  no  don’t know  refused Date of Birth:______Sex:  Male  Female Race: ______Income Source:______$$______ Hispanic  Pregnant Number of Months Pregnant______Disabled  Yes  No Disability/Medical Problem______Relationship to Applicant:______SSN:______-_____-______Education: ______Last Name:______First Name:______Middle Name:______Last Perm. Address for Adult, if different than HoH ______City______State ______Zip______Veteran:  yes  no  don’t know  refused Date of Birth:______Sex:  Male  Female Race: ______Income Source:______$$______ Hispanic  Pregnant Number of Months Pregnant______Disabled  Yes  No Disability/Medical Problem______Relationship to Applicant:______SSN:______-_____-______Education: ______Last Name:______First Name:______Middle Name:______Date of Birth:______Sex:  Male  Female Race: ______Income Source:______$$______ Hispanic  Pregnant Number of Months Pregnant______Disabled  Yes  No Disability/Medical Problem______Emergency Contacts: Primary Contact: Relationship:______Name:______Address:______City:______State: ______Zip:______Phone Number: ______Secondary Contact: Relationship:______Name:______Address:______City:______State: ______Zip:______Phone Number: ______Application Affirmation & Authorization to Verify Information APPLICATION STATEMENT: I certify that the above information is an accurate and complete disclosure of the requested information. I hereby acknowledge that the information relating to determination of my eligibility requires verification and/or documentation, and by my signature, I authorize the release of such information as may be required for the determination of my eligibility. Signature of Applicant ______Date:______

Intake Worker Signature ______Date:______NOTES: Date:______

Relationship to Applicant:______SSN:______-_____-______Education: ______Last Name:______First Name:______Middle Name:______Date of Birth:______Sex:  Male  Female Race: ______Income Source:______$$______ Hispanic  Pregnant Number of Months Pregnant______Disabled  Yes  No Disability/Medical Problem______Relationship to Applicant:______SSN:______-_____-______Education: ______Last Name:______First Name:______Middle Name:______Date of Birth:______Sex:  Male  Female Race: ______Income Source:______$$______ Hispanic  Pregnant Number of Months Pregnant______Disabled  Yes  No Disability/Medical Problem______Relationship to Applicant:______SSN:______-_____-______Education: ______Last Name:______First Name:______Middle Name:______Date of Birth:______Sex:  Male  Female Race: ______Income Source:______$$______ Hispanic  Pregnant Number of Months Pregnant______Disabled  Yes  No Disability/Medical Problem______Relationship to Applicant:______SSN:______-_____-______Education: ______Last Name:______First Name:______Middle Name:______Date of Birth:______Sex:  Male  Female Race: ______Income Source:______$$______ Hispanic  Pregnant Number of Months Pregnant______Disabled  Yes  No Disability/Medical Problem______Relationship to Applicant:______SSN:______-_____-______Education: ______Last Name:______First Name:______Middle Name:______Date of Birth:______Sex:  Male  Female Race: ______Income Source:______$$______ Hispanic  Pregnant Number of Months Pregnant______Disabled  Yes  No Disability/Medical Problem______Relationship to Applicant:______SSN:______-_____-______Education: ______Last Name:______First Name:______Middle Name:______Date of Birth:______Sex:  Male  Female Race: ______Income Source:______$$______ Hispanic  Pregnant Number of Months Pregnant______Disabled  Yes  No Disability/Medical Problem______Relationship to Applicant:______SSN:______-_____-______Education: ______Last Name:______First Name:______Middle Name:______Date of Birth:______Sex:  Male  Female Race: ______Income Source:______$$______ Hispanic  Pregnant Number of Months Pregnant______Disabled  Yes  No Disability/Medical Problem______Relationship to Applicant:______SSN:______-_____-______Education: ______Last Name:______First Name:______Middle Name:______Date of Birth:______Sex:  Male  Female Race: ______Income Source:______$$______ Hispanic  Pregnant Number of Months Pregnant______Disabled  Yes  No Disability/Medical Problem______

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