Apply for Housing & Support

Name

First

Last

Email

Phone

Agency You Work With

Birth Date

Age

Marital Status

Race

Ethnicity

Gender

Are you a Veteran?

Yes
No

Do you have an ID card?

Yes
No

(Driver's License or State ID)

Do you have an EBT card?

Yes
No

Working

Yes
No

DOC Housing Voucher

Yes
No

Social Security Benefits

Yes
No

Social Security Disability Benefits

Yes
No

Drug Court Housing

Yes
No

HEN Program

Yes
No

VASH Funding

Yes
No

Healthcare

Medicaid

Yes
No

Both

Yes
No

Other

Yes
No

Please provide information about any medications here

Have you ever lived in shared housing

Have you ever lost housing?

Please describe your situation here.

Do you have any debt or LFOs?

Other

Incarceration or Arrests

Any charges pending?

What organizations help you or case managers providing resources?

Work History

Are you working or looking for work?

Do you plan on school or training and what type of training?

Is there anything you want Susie to know about you?

What are your goals and plans?

I acknowledge that I have read the house rules and agree to comply with the house rules

Yes

Consent To Procedure and Access To Medical Records

Worthy Heart Foundation requires random urinalysis tests in the house and as a condition to entry to the house and remaining in the program. We do not require access to medical information, unless there is an emergency in the house, Or you are on medication prescribed by a physician or on a medically assisted treatment for addiction. Please initial where indicated.

Initials Here

1.1 Consent to Procedures: To arrange for and consent for urinalysis.

1.2 Access to Medical Records and Other Personal Information: The Client hereby allows physicians and psychiatrists who have treated the Client, and all other providers of health care, including hospitals, to release to the Worthy Heart Foundation information needed for medically assisted treatment as needed for supportive housing. With respect to the Worthy Heart Foundation only, the Client hereby waives all privileges attached to the physician patient relationship and to any communication, verbal or written, arising out of such a relationship. The Worthy Heart Foundation is authorized to request, receive and review any information, verbal or written, pertaining to the Client’s physical or mental health, including medical and hospital records, and to execute any releases, waivers or other documents that may be required in order to obtain such information, and to disclose such information to such persons, organizations and health care providers as the Worthy Heart Foundation may designate

Client Name

Your First and Last Name

Photo Consent Form

I, the undersigned, of legal age, hereby irrevocably grant to WORTHY HEART FOUNDATION (www.worthyheartfoundation.org) its subsidiaries, affiliates, agents, licensees, successors and assigns thereof (hereinafter referred to as “Company”), claiming under or through same, the following rights to use the materials and/or items described herein in any fashion, form, or media, whether currently in existence or hereinafter devised:

1. The right to photograph, record, videotape, store, and use the undersigned’s name, voice, appearance, likeness, signature and/or written testimony or statement along with any material furnished by me, in whole or in part, in any training, training materials and/or advertising materials produced, used or provided by Company, its subsidiaries, affiliates, agents, licensees, successors and assigns thereof, through means of mass, digital, and/or electronic media, including but not limited to printed, radio and television, promotional materials or events, and/or marketing plan, the Internet, and any other media and for all other types of advertising, publicity, promotion and other trade purposes for Company, its products and services;

2) The right to publish, text, exhibit, distribute and use the written or recorded testimonial or statement, or any parts thereof, my likeness and image, which shall appear as follows: first name and surname, general location of residence, and, where applicable, accompanied by photographs and/or recordings and/or signature, for commercial and/or non-commercial purposes, including but not limited to the advertising or solicitation of purchases, anywhere in the world where Company conducts business or intends to conduct business. I, the undersigned, hereby grant Company full ownership of and complete interest in any copyright I may have with regard to any written statement or other tangibly-fixed expression, which I have provided. I, the undersigned, hereby release and agree to indemnify and hold harmless Company, its subsidiaries, affiliates, officers, directors, agents, owners, employees, successors and assigns thereof, from any and all claims, actions, causes of action, damages, expenses, courts costs, attorney fees, liability damage or judgment suffered by the undersigned regarding the undersigned’s participation in or testimonial furnished by the undersigned to Company. I, the undersigned, hereby acknowledge that I have not been paid or otherwise compensated for the rights granted above. I further certify that all material, whether verbal, written or exhibited by me is not scripted or coached and represents my individual opinions and beliefs, and are true and correct to the best of the my knowledge. I, the undersigned, hereby acknowledge that I have read this document and understand its contents. I further acknowledge that I have executed this document voluntarily

Client Name

Your First and Last Name

Voucher you you

Emergency Contacts (Family or friends)

Emergency Contact #1 Name

First

Last

Emergency Contact #1 Relation

Emergency Contact #1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact #1 Phone

Emergency Contact #2 Name

First

Last

Emergency Contact #2 Relation

Emergency Contact #2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact #2 Phone

What is your immediate need when you enter housing (Examples: clothing, dental care, referalls for services)

Do you have children and what are their ages?

Counselor

Resident Signature

Type your First and Last Name