GILA House emergency program   application

Date ______________ Mentor:__________________________ Phone_________________________ Proposed Emergency Shelter Entry Date:_____________     Exit Date_______________________ 

Client 1. Name___________________________Social Security Number:______________________
Date of Birth_____________________________Phone Number:_____________________________
Relationship:_______________________________
US Citizen______Non-Citizen_____
Client 2. Name___________________________Social Security Number:______________________
Date of Birth_____________________________Phone Number:_____________________________
Relationship:_______________________________
US Citizen______Non-Citizen_____
Children Data:
Name:____________________________DOB_______________SSN:______________________
Name:____________________________DOB_______________SSN:______________________
Name:____________________________DOB_______________SSN:______________________
Name:____________________________DOB_______________SSN:______________________

Employment or Rehabilitation Information:
NOTE: All adults in GILA House Emergency Program must be participating in full-time activities, such as job search, employment, education, or mental health / substance abuse treatment. Please answer the following about the activity you are taking part in. 
Name of employer, school, or treatment facility: _______________________________________
Date you began participating in the above: _______________Pay Rate:______________________
Your weekly number of hours in this activity: _________________________________________
Date you anticipate finishing the activity: ____________________________________________
If you are participating in more than one activity, please list all of the above information for your second activity here. 
Date you began participating in the above: _______________ Pay Rate:_____________________
Your weekly number of hours in this activity: _________________________________________
Date you anticipate finishing the activity: ____________________________________________
Schooling Information:
Total under school age children? _____Number of children currently in daycare?_________ 
Daycare name: ___________________________ Location_________________________________
Phone Number:___________________________

If under school age children are not in daycare, please explain why: 

If children are of school age, are they enrolled in, attending school?______
School Name: __________________________Location__________________________________
School Name: __________________________Location__________________________________
     
If school age children are not enrolled in school, please give reasons why:

Are any adults in household receiving SSI or SSDI? ________ Amount of each: ________________
If Yes, for what reason(s)? 

Emergency Contacts:

a)	Name:____________________________Relationship:._________________________

Address: __________________________________ 	Phone: ____________________

b)	Name: ___________________________Relationship:.__________________________

Address: __________________________________ 	Phone: _____________________

Housing History:

a.	Last Address:__________________________________________________________________
b.	Landlord:_____________________Address:__________________________________________
c.	Reason for leaving:______________________________________________________________

d.	Previous Address:_______________________________________________________________
e.	Landlord:____________________Address:___________________________________________
f.	Reason for leaving:______________________________________________________________

g.	Where have you sought housing prior to coming here?__________________________________

h.	If you have been involuntarily terminated by another shelter, please describe the 
circumstances.

i.	Have you ever been evicted before? ______ If yes, please explain reasons:

j.	How many times have you been homeless in the last five years?_____

k.	What do you believe is the cause of your homelessness or potential homelessness?

l.	Can your family or relatives assist you with housing?___________________________________   

Please explain:____________________________________________________________________
________________________________________________________________________________

Narrative:
Please explain, in detail, why your family wants to reside in the Emergency Housing Program. Include ways in which you feel your family could benefit, and what goals (short-term as well as long-term), that you feel your family could obtain while staying at GILA House. 
_________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you able to pay for Gas and Electric utilities you used during your stay at the GILA House?

If insurance reimbursement for temporary living expenses is available from my insurance company, I agree to apply for this benefit and reimburse the GILA House whenever I receive this benefit.
Signature:____________________________________Date:_________________________

Where do you see yourself in three months?________________________________________

_______________________________________________________________________________

In one year? _______________________________________________________________________________

Required Drug and Background Checks
Prior to being considered for the Emergency Housing Program, all adults in the household (over 16 years old) must first submit a urinalysis at Dalmolin Chiropractic. Test results must come back clean for any and all drugs. All clients will also be subject to random drug testing throughout the program. 
Prior to being considered for the Emergency Housing Program, all adults in the household also must agree, without reservation, to a search of his or her background in the areas of credit history, criminal conviction history, sexual misconduct, and general public history prior to being accepted into the program and agree to comprehensive reference verification. 
Your signature(s) below acknowledge(s) that you understand this policy and that you are willing to permit this background check and to submit to a urinalysis upon request.  

Adult #1__________________________________________Date__________________________
Adult #2__________________________________________Date__________________________
Adult #3__________________________________________Date__________________________
Adult #4__________________________________________Date__________________________
Parental Consent_____________________________ Date___________________

Underage Minors names:   _____________________________________________

Please complete the attached Budget Sheet for the current month.  When finished, please return entire application to your Mentor.
NOTE: Although the Emergency Program is available to clients for up to 90 days, all clients are encouraged to work toward their goals so that they may become self-sufficient prior to then.  Mentors will provide continual support, but your success will depend upon your own commitment. You will have many responsibilities to fulfill, including establishing realistic goals, applying budgeting principles, following your case plan, and abiding by GILA House rules.

Financial Disclosure:
How much money do you currently have in savings? _____________________
Monthly Income
	1
	2
	3
	4
	5
	6
	
Self #1

	

	
	
Self #2

	

	
	
Spouse #1

	

	
	
Spouse #2

	

	
	
Total Monthly Income

	

	

Rent/Housing

	

	
	
Electricity

	

	
	
Gas

	

	
	
Water

	

	
	
Garbage

	

	
	
Telephone

	

	
	
Groceries

	

	
	
Hygiene Items

	

	
	
Meals Out

	

	
	
Car Payment

	

	
	
Auto Insurance

	

	
	
Gas/Transportation

	

	
	
Child Care

	

	
	
Child Support

	

	
	
Credit Card

	

	
	
Credit Card

	

	
	
Tobacco

	

	
	
Entertainment

	

	
	
Probation Fees

	

	
	
Total income minus debt
debt

	

	

	

Documents needed for intake are as follows:
State Issued Picture ID
Is a must for all ADULTS

Social Security Cards
For all members of the family

BIRTH CERTIFICATES
Passport or Drivers License after 1996 if no Birth Certificate

For all members of the family, please make sure you have

ALL DOCUMENTS IN YOUR POSSESSION if possible!

THE DOCUMENTS ABOVE ARE OF EXTREME IMPORTANCE!

In consideration for receiving permission to participate in the GILA House Program, I hereby release, waive, discharge and covenant not to sue the GILA House organization, its officers, servants, agents and employees (hereinafter referred to as "releasees") from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or relating to any loss, damage or injury, including death, that may be sustained by me, or to any property belonging to me, whether caused by the negligence of the releasees, or otherwise, while participating in the GILA House Program, or while in, on or upon the premises or facilities leased or operated by the GILA House Organization.

Adult #1____________________________________Date__________________
Adult #2____________________________________ Date__________________
Adult #3____________________________________Date__________________
Adult #4____________________________________ Date___________________