<p> WOMANSPACE EAST, INC. APPLICATION FOR TRANSITIONAL HOUSING PROGRAM</p><p>Dear Applicant: Please complete the entire application and give your utmost attention to answering the information stated below. Please return the application as soon as possible to Womanspace East, Inc., Transitional Housing Program, Case Manager, P.O. Box 3826, Pittsburgh, PA 15230, or fax to 412-765-3830. You may be called for an interview if spaces are available. In the event you receive an interview, it should not be construed that you have been accepted into the Transitional Housing Program. </p><p>NAME: ______ID# CODE: ______DATE: ______Current Living Status/Facility: ______Date Entered Shelter Program: ______Marital Status: ______Social Security Number: ______Birth Date: ______Age: ______Is this your first time homeless? ______How many times in the last three years? ______Are you a Veteran? ______</p><p>Education: Check appropriate item(s): ______Did not finish High School ______GED ______High School Diploma ______College, Years ______Graduate School ______Adult Basic Education ______Trade/Vocational School, Certification: ______</p><p>Source of Benefits and Income and Amount ($) per month: $______Employment $______Unemployment $______DPA, Welfare $______Food Stamps $______Child Support $______Social Security(SSI) $______Veterans Pension $______Disability, type:______$______Other (Please specify) ______Medical Assistance ______Other Health Care Insurance Provider WSE Transitional Housing Program Application Page 2</p><p>Name of Current Employer: ______Name of Current Educational Program: ______Location of Public Assistance Office: ______Case #: ______Phone Number ______Caseworker: ______Name of Primary Care Physician:______Phone#:______Do you have any medical conditions we should be aware of? ______No ______Yes If Yes, ______Are you currently receiving treatment for any of the above conditions? ______No ______Yes Name and dosage of medication for above conditions: ______</p><p>What do you feel you have accomplished during your stay at the crisis shelter? ______</p><p>How would you describe your relationship with the other women and children at the crisis shelter? ______</p><p>How would you describe your experiences in a community living situation? ______</p><p>What do you see as its strengths and weaknesses? ______WSE Transitional Housing Program Application Page 3</p><p>List 3 personal strengths: List 3 personal weaknesses: 1. ______1. ______2. ______2. ______3. ______3. ______</p><p>What was the crisis that brought you into shelter? ______</p><p>What has kept you from being independent in the past? ______</p><p>Current Debts Owed and Amount: ______</p><p>What do you want to accomplish at the Womanspace East Transitional Housing Program? (Goals, Short-Term) 1. ______2. ______3. ______</p><p>What do you want to be doing one year from today? (Goals, Long-Term) 1. ______2. ______3. ______WSE Transitional Housing Program Application Page 4</p><p>Child’s Full Name Date of Birth Age Sex Social Security Number</p><p>How would you describe your relationship with your children? ______Name of Pediatrician:______Phone #:______Do your children have any medical conditions we should be aware of? ______No ______Yes If Yes, ______Are your children currently receiving treatment for any of the above conditions? ______No_____Yes Name and dosage of medication for above conditions: ______</p><p> </p><p>History of Domestic Abuse/Intimate Partner Violence: Have you ever been in an abusive relationship?______Have you ever received counseling for domestic abuse/intimate violence? ______Are you still in counseling? ______How many times have you left your abuser? ______Do you have a PFA? ______Do you need one? ______Your current relationship with your abuser: _____Still together ______No involvement ______Other ______Any involvement in court with custody of children? ______Last contact with abuser? ______Do your children visit your abuser? ______</p><p>WSE Transitional Housing Program Application Page 5</p><p>History of Addiction: Do you/did you ever have a problem with drugs or alcohol? ______No ______Yes Would you define yourself as an addict/alcoholic? ______No ______Yes What was/is your drug or drink of choice? ______How much did/do you consume and how often? ______When did you last use? ______What treatment facility(s) were you in? When were you there? ______Date last drug/alcohol treatment program was completed: ______What program(s) are you currently involved with?______How often do you attend treatment? ______</p><p>History of Mental Health: Have you ever received mental health treatment? ______How long ago? ______Where? ______Are you currently attending mental health treatment? ______If yes, where? ______Name of therapist and psychiatrist: ______What was/is your diagnosis? ______Do you take medication? ______How often?______If yes, what is the name of your medication? ______</p><p>Criminal History: Have you ever been convicted of a crime? If yes, what? ______Do you have any outstanding charges? If yes, what? ______Balance owed on any outstanding fines: ______</p>