- Hope Found Here

Forge Application

John 5:6 “Do you want to get well?”

Basic Information

Today's Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

DOB(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Marital Status(Required)

Phone(Required)

Backup Contact Email

Introduction

What are the main issues in your life that you need help with?(Required)

How do you feel this program can help you?(Required)

Do you struggle with continuous homelessness?(Required)

Yes

If so, what typically causes your homelessness?

What significant issues would you say you struggle with most?(Required)

Drug / Alcohol Addiction

Would you say you currently have a drug or alcohol problem?(Required)

Yes

If yes, please describe

When did this problem begin?(Required)

When is the last time you drank?(Required)

When was the last use of illegal drugs?(Required)

Have you been through any other programs?(Required)

Yes

If yes, list programs and dates:

Are you currently participating in any other programs (recovery/court ordered/etc.)?(Required)

Yes

If yes, please explain:

Legal Information

Do you have any pending charges?(Required)

Yes

If yes, please explain:

Have you been convicted of a felony?(Required)

Yes

If yes, please explain:

Have you been convicted of a misdemeanor?(Required)

Yes

If yes, please explain:

Are you currently on probation/parole?(Required)

Yes

If yes, please explain:

Do you owe any court fines?(Required)

Yes

If yes, please explain:

Do you have any legal obligations to the Friend of the Court?(Required)

Yes

If yes, please explain:

Have you or do you currently have a CPS Case?(Required)

Yes

If yes, who is your CPS Case Worker?

Health Information

Describe your current health condition/concerns:(Required)

Do you have any chronic or acute conditions that might impact your ability to work?(Required)

Yes

Please describe:

Do you have, or should you have, any restrictions for lifting, standing, walking or repetitive movement?(Required)

Yes

If yes, what are they?(Required)

Do you have any planned, or have you been told you should have, any surgeries in the next year?(Required)

Yes

If yes, please explain:

Are you currently taking any medications?(Required)

Yes

If yes, please explain:

Are you struggling with any mental health issues and/or working with any mental health agencies?(Required)

Yes

If yes, please explain:

Are you or have you been a client of Community Mental Health?(Required)

Yes

If yes, in what county?

Are you currently working with any additional outside agencies(Required)

Yes

If yes, which ones?

Employment and Training Information

Have you had difficulty holding steady employment?(Required)

Yes

If yes, why?

What type of jobs have you worked in the past?(Required)

Financial Information

What are your current sources of include? And what is the amount per month?(Required)

Would you have any required payments to make while in the Forge program?(Required)

Yes

If yes, what are they?

Transportation

I have a…(Required)

State ID

Valid driver’s license

Neither

In what state?

Parenting/Child Care

Do you have any children?(Required)

Yes

If yes, are they currently in your care?

Please list the names and ages of your children and whose custody they are in:(Required)

Do any of your children have behavioral or health issues that would impact them going to childcare or school on a regular basis or living in a busy environment?(Required)

Yes

If yes, please list:

Are your children receiving any mental health services or are they on medication for mental health concerns?(Required)

Yes

If yes, please explain:

Are you required to pay child support?(Required)

Yes

If yes, how much?

Arrears amount?

Do you have any legal issues concerning your children (i.e., foster care, custody issues, child protective services involvement, etc.)?(Required)

Yes

If yes, please explain:

Are your children enrolled in school or childcare?(Required)

Yes

Do any of your school age children participate in extracurricular activities or after-school programs?(Required)

Yes

If yes, please explain:

Forge Application

John 5:6 “Do you want to get well?”

Basic Information

Today's Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

DOB(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Marital Status(Required)

Phone(Required)

Backup Contact Email

Introduction

What are the main issues in your life that you need help with?(Required)

How do you feel this program can help you?(Required)

Do you struggle with continuous homelessness?(Required)

Yes

If so, what typically causes your homelessness?

What significant issues would you say you struggle with most?(Required)

Drug / Alcohol Addiction

Would you say you currently have a drug or alcohol problem?(Required)

Yes

If yes, please describe

When did this problem begin?(Required)

When is the last time you drank?(Required)

When was the last use of illegal drugs?(Required)

Have you been through any other programs?(Required)

Yes

If yes, list programs and dates:

Are you currently participating in any other programs (recovery/court ordered/etc.)?(Required)

Yes

If yes, please explain:

Legal Information

Do you have any pending charges?(Required)

Yes

If yes, please explain:

Have you been convicted of a felony?(Required)

Yes

If yes, please explain:

Have you been convicted of a misdemeanor?(Required)

Yes

If yes, please explain:

Are you currently on probation/parole?(Required)

Yes

If yes, please explain:

Do you owe any court fines?(Required)

Yes

If yes, please explain:

Do you have any legal obligations to the Friend of the Court?(Required)

Yes

If yes, please explain:

Have you or do you currently have a CPS Case?(Required)

Yes

If yes, who is your CPS Case Worker?

Health Information

Describe your current health condition/concerns:(Required)

Do you have any chronic or acute conditions that might impact your ability to work?(Required)

Yes

Please describe:

Do you have, or should you have, any restrictions for lifting, standing, walking or repetitive movement?(Required)

Yes

If yes, what are they?(Required)

Do you have any planned, or have you been told you should have, any surgeries in the next year?(Required)

Yes

If yes, please explain:

Are you currently taking any medications?(Required)

Yes

If yes, please explain:

Are you struggling with any mental health issues and/or working with any mental health agencies?(Required)

Yes

If yes, please explain:

Are you or have you been a client of Community Mental Health?(Required)

Yes

If yes, in what county?

Are you currently working with any additional outside agencies(Required)

Yes

If yes, which ones?

Employment and Training Information

Have you had difficulty holding steady employment?(Required)

Yes

If yes, why?

What type of jobs have you worked in the past?(Required)

Financial Information

What are your current sources of include? And what is the amount per month?(Required)

Would you have any required payments to make while in the Forge program?(Required)

Yes

If yes, what are they?

Transportation

I have a...(Required)

State ID

Valid driver's license

Neither

In what state?

Parenting/Child Care

Do you have any children?(Required)

Yes

If yes, are they currently in your care?

Please list the names and ages of your children and whose custody they are in:(Required)

Do any of your children have behavioral or health issues that would impact them going to childcare or school on a regular basis or living in a busy environment?(Required)

Yes

If yes, please list:

Are your children receiving any mental health services or are they on medication for mental health concerns?(Required)

Yes

If yes, please explain:

Are you required to pay child support?(Required)

Yes

If yes, how much?

Arrears amount?

Do you have any legal issues concerning your children (i.e., foster care, custody issues, child protective services involvement, etc.)?(Required)

Yes

If yes, please explain:

Are your children enrolled in school or childcare?(Required)

Yes

Do any of your school age children participate in extracurricular activities or after-school programs?(Required)

Yes

If yes, please explain:

Forge Application

Basic Information

Introduction

Drug / Alcohol Addiction

Legal Information

Health Information

Employment and Training Information

Financial Information

Transportation

Parenting/Child Care

Forge Application

Basic Information

Introduction

Drug / Alcohol Addiction

Legal Information

Health Information

Employment and Training Information

Financial Information

Transportation

Parenting/Child Care

Know Your Impact

Worthy of Your Trust.