Professional Documents
Culture Documents
New Visions Veterans Program Application
New Visions Veterans Program Application
DOB
Current Address
City
Age
Sex
Race
State
Hisp.
Zip code
Can we leave a message with the phone number listed above? Yes
Phone
No
Medicare
FIP
SSI
SSD
IVA
Unemployment
Food Stamps
General Assistance
Workmans Compensation
Pensions
Retirement Acc.
Alimony
Child Support
Section 8 DO Waiver
Yes No
Yes
Yes No
Yes
No
No
If you answered yes above, what branch did you serve in? __________________ Discharge Type:________
Married
Seperated Divorced
Widowed
Not Married
- Revised 06/2012
If you answered yes above, please list the names, addresses, and phone numbers of your current
service providers: (please use additional pages and attach to back of application if necessary)
Position:
Address / Phone:
Name:
Psychologist / Counselor
Social Worker / Case Manager
Financial Manager
Other:
Other:
Other:
Please list all you current medications and dosages: (please list over the counter medications, herbs, and supplements)
Medications
Prescribing Doctor:
Please list any counseling/mental health agencies that you have received treatment from in the past, including in-patient hospitalizations, out-patient hospitalizations, outpatient psychiatry, counseling, and/
or case management: (please use additional pages and attach to back of application if necessary)
Facility Name and Location:
Substance Treated:
- Revised 06/2012
Dates:
Have you used any substances in the past year? (please check all that apply)
Alcohol
Amphetamines
Cocaine/Crack
Marijuana
Inhalants
Yes
No
Location:
Date:
Yes
No
If yes, please list the name, address, and phone number of parole officer(s):____________________________
________________________________________________________________________________________
Are you currently listed on the sex offenders registry: Yes No
Offense:____________________
Irregular Work
Volunteer
Student
PSR/ Therapeutic
Day Program
None
List the name, address, phone number of place of employment or other day structure:____________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
What is the highest level of education completed: ______________________________________________
The Christian Worship Center D.B.A. New Visions Homeless Services
- Revised 06/2012
Yes
No
Describe the circumstances for being homeless at this time: (include where you are currently residing)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
All applications are processed in the order received. Thank you for taking the time to apply for one of our programs. Not all applicants are admitted into program.
Someone will contact you as soon as possible concerning your application process and review. Thank You.
- Revised 06/2012