Casa Pacifica Housing Application

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1 Casa Pacifica Housing Application Name General Information US Citizen: No Phone Number Age Date of Birth Place of Birth Cell Number Emergency Contact Name Relationship of Contact Contact Phone Number In Foster Care Now? Name of Social Worker Did You Exit Foster Care? Date Exited Foster Care County of Foster Care Social Workers Phone Number Employment History Most Recent Employer Company Name Are you still Employed Company Phone Number Supervisors Name Supervisors Phone Number Dates of Employment Position Held Salary Full Time Part Time Brief Job Description: How many Hours Per Week Reason for Leaving May We Contact Employer Casa Pacifica Housing Application Page 1

2 Company Name Are you still Employed Company Phone Number Supervisors Name Supervisors Phone Number Dates of Employment Position Held Salary Full Time Part Time Brief Job Description: How many Hours Per Week Reason for Leaving What are your career goals? May We Contact Employer Did you Graduate High School Are You Currently Attending School? Class Schedule Education Information High School Diploma School Attending GED Date Completed Date Started What are your educational goals? Do you have medical insurance Doctors Name Community Life Functioning Insurance Company Name Insurance # Do you have a primary Dr. Doctors Phone Number Have you been diagnosed with a serious Illness? If yes, please describe below: Are you experiences a medical condition/physical symptoms you attribute to mental, emotional, or stress-related conditions? If yes, please describe below: Casa Pacifica Housing Application Page 2

3 Do you drink alcohol? How much per week? Have you received mental health treatment before? Personal Wellbeing Do you currently use illegal drugs? Dates Have you ever used illegal drugs? How long? Have you ever attempted suicide? If yes, please describe circumstances below: Do you have a Bank Account Do you owe anyone money Do you have a Drivers License? Do you own a car? Do you have car insurance? Car Insurance Policy Number Name of Probation Officer Financial History Balance of Checking Balance of Savings Do you have a Credit Card How much total? Drivers License #: Have you ever developed a personal budget? Other Year / Make / Model of Car Do you have a California ID? Car Insurance Provides Name Have you ever been on probation? Balance owed Would you like to learn? California ID #: License # of Car: Are you currently on Probation? Probation Officer Phone Number References Casa Pacifica Housing Application Page 3

4 In Order For Your Application To Be Considered The Following Questions Must Be Completed Please briefly state why you are interested in living in CITY s Transitional Housing Program? Please briefly state your current living situation? Please describe what qualities would make you a good candidate for CITY s Transitional Housing Program? Please describe some obstacles you have faced in the past and how you have overcome them: What are some challenges you think you may face if you are accepted into CITY s Transitional Housing Program? Applicants Signature Date Casa Pacifica Housing Application Page 4

5 For Transitional Services Staff Use Only Date Received CITY Participant Intake Needed Schedule Interview Interview Date: Accepted Declined Incomplete Application Housing Option: Stepping Stone Community Nest The Shire Date: Signature Casa Pacifica Housing Application Page 5

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