APPLY FOR A ROOM

Paul's House Admission Application For Male Veterans

 

Administrator_______________________ Date______________


Name: First________________________ MI_______Last____________________________

Social Security No.:________________________

Date of Birth:____________          Age:______

Are you a US Citizen?      YES   NO

Are you a Veteran?          YES   NO

Branch of Service:________________________                Service No.:__________________

Dates Served

From:_____________To:_______________

Type of Discharge______________________________________

Cell No.______________________________________________

Do you have any of the following forms of identification?

VA Card: YES    NO

DD-214:  YES    NO 

Drivers License: YES    NO

(Need copy of all ID forms and picture of the guest for file)

Who referred you to Paul's House?__________________________________________

Do you currently have a case worker?   YES   NO

If yes, please give Name:________________________ Phone:____________________

Your last address:

Street:_________________________________________________Apt. #:_________

City:____________________________State:________________Zip Code_________

Where are you currently living?____________________________________________

Married or Single:______________________

Family member: Name:_________________________Relationship:_______________

Address:_____________________________________________________Apt.______

City:________________________________State:____________Zip Code:_________

Phone No.:_____________________

Do we have your permission to contact them?   YES    NO

Highest level of education completed: _______________________________________

Degrees and Trade Certificates: ____________________________________________

Are you currently receiving any Income?   YES      NO

If yes, list source and amount:_____________________________________________

Medical Issues

Do you have a problem with drugs or alcohol?   YES    NO

Do you have any health problems?   YES   NO

If yes, please explain:__________________________________________________________

___________________________________________________________________________

Do you have a primary care physician?   YES   NO

Doctor's Name:____________________________________ Phone:_____________________

Do you have medical coverage/insurance?    YES    NO

List:________________________________________________________________________

Are you in the VA system?   YES   NO

Which hospital?_______________________________________________________________

Our facility is not handicap accessible. Can you climb stairs without assistance?   YES   NO

Can you perform light manual labor required to maintain the facility?   YES   NO

Are you currently taking any medications?   YES   NO

If yes, please list below (name, how often, reason):

_________________ ___________________ __________________

_________________ ___________________ __________________

_________________ ___________________ __________________

Do you require a special diet?    YES    NO

Explain if yes:__________________________________________________________________

_____________________________________________________________________________

Do you have any allergies?   YES   NO

List if yes: ____________________________________________________________________

Legal Issues

Have you ever been convicted of a felony?   YES   NO

What is your current legal status?   FREE & CLEAR  -  PROBATION  -  PAROLE

Transportation

Do you own a car?   YES   NO

Make:________________________ Year:____________ Plate No.:__________________